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THE  SURGERY  OF  THE 
HEART    AND    LUNGS 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/surgeryofheartluOOrick 


Plate   I. 


AXTERIOK  \'II-:\V  OF  HiiART  AND  LuXGS  OF  DoG,  IxjECTED 

IX  Situ. 


(Page  484) 


THE   SURGERY   OF   THE 
HEART  AND    LUNGS 

A  HISTORY  AND  RESUME  OF  SURGICAL 
CONDITIONS  FOUND  THEREIN,  AND  EX- 
PERIMENTAL AND  CLINICAL  RESEARCH 
IN  MAN  AND  LOWER  ANIMALS,  WITH 
REFERENCE  TO  PNEUMONOTOMY,  PNEU- 
MONECTOMY AND  BRONCHOTOMY,  AND 
CARDIOTOMY    AND     CARDIORRHAPHY 


By 

Benjamin  Merrill  Ricketts,  Ph.B.,  M.D. 

MEMBER  AM.  MED.  ASSN.;  WESTERN  SURG.  AND  GYN.  ASSN.;  INT.  MED.  CONG., 
1887;  INT.  ASSN.  RAILWAY  SURGEONS;  MISS.  VALLEY  MED.  ASSN.;  CIN'TL 
ACAD.  OF  MED.  ;  OHIO  STATE  MED.  SOC.  ;  AM.  PROCTOLOGIC.  SOC.  ;  HON.  MEM. 
MED.  SOC.  STATE  OF  N.  Y.  ;  HON.  MEM.  ST.  LOUIS  MED.  SOC.  ;  FELLOW  NEW 
YORK  STATE  MED.  ASSN.,  AND  MEM.  SOCI^TE  INTERNATIONALE  DE  CHIRURGIE 


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THE    GRAFTON    PRESS 
NEW   YORK  MCMIV 


Copyright,  1 904,  in  the  United 
States  and  Great  Britain  by 
THE    GRAFTON    PRESS 


9^  I  <^~ 


DEDICATION 

This   Work  is  offered  as  a  Token  of  Respect 

and   Admiration   to   My   Father 

Gerard  Robinson  Ricketts,  M.D., 

and  to  the  Surgeons  who  have  had  the  Courage 

to  Perform   Surgical   Operations  of  Any 

Character  upon  the  Living  Human 

Heart  or  Lungs 


PREFACE 

The  author  in  his  work  as  a  surgeon  has  been  brought  in 
contact  with  several  cases  of  pulmonary  trouble  requiring 
surgical  intervention,  and  has  thus  become  greatly  interested 
in  the  subject. 

On  taking  up  the  study  he  found  that  there  was  no  one 
work  on  surgery  that  gave  more  than  a  brief  space  to  this 
subject.  In  order  to  obtain  a  knowledge  of  the  operative 
surgery  of  the  lung,  or  even  a  complete  description  of  all  the 
pulmonary  lesions  requiring  surgical  intervention,  the  stu- 
dent is  forced  to  consult  many  works,  and  journals  in  many 
languages. 

For  his  own  convenience  the  author  collected  a  large  mass 
of  material,  and  compiled  several  bibliographies  bearing  on 
this  subject. 

He  also  found  that  many  questions  regarding  the  tech- 
nique of  lung  surgery  were  in  doubt.  In  order  to  settle  these 
questions  to  his  own  satisfaction,  he  made  a  series  of  original 
experiments  on  dogs. 

Considering  the  paucity  of  information  contained  in  the 
standard  treatises,  and  the  inaccessible  sources  of  the  most 
valuable  matter,  the  author  thought  that  a  work  of  this  char- 
acter might  prove  acceptable  to  students. 

Part  of  this  work  is  an  historical  compilation,  in  an  acces- 
sible form,  of  papers  and  reports  scattered  through  the  va- 
rious journals  of  this  and  other  countries,  together  with  a 
bibliography  of  the  subject. 

For  this  part,  no  originality  is  claimed,  but  for  the  other 


Vlll  PREFACE 

part,  which  details  the  author's  experiments  on  dogs  and  the 
results  obtained,  he  claims  entire  originality. 

No  attempt  has  been  made  to  write  an  exhaustive  treatise 
on  the  surgery  and  surgical  diseases  of  the  lungs,  but  an  ef- 
fort to  consider  all  the  diseases  of  the  lung  which  may  call 
for  surgical  intervention. 

Space  has  been  devoted  to  each  disease  in  proportion  to 
its  importance. 

This  work  is  especially  intended  for  practitioners  and  stu- 
dents. For  this  reason  the  descriptions  of  each  disease,  with 
its  symptoms,  diagnosis,  and  treatment,  have  been  made  as 
concise  as  possible;  the  aim  being  to  enable  the  practi- 
tioner to  recognize  the  various  surgical  diseases  of  the  lung, 
in  order  that  he  may  seek  surgical  assistance  promptly  when 
necessary. 

Each  chapter  has  its  own  bibliography,  so  that  those  de- 
siring information  on  any  particular  subject  need  not  con- 
sult a  great  mass  of  matter  in  which,  perhaps,  they  have  no 
interest. 

The  reader  must  not  think  that  all  the  works  and  reports 
mentioned  have  been  read  by  the  author;  this  would  be  a 
physical  impossibility  for  a  man  actively  engaged  in  his  pro- 
fession. 

The  most  important,  however,  have  been  perused,  every 
statement  and  reference  has  been  verified  and  the  authority 
for  all  statements  has  been  given. 

This  has  been  done  in  order  that  credit  might  be  given 
where  it  is  due,  and  also  that  the  author  of  this  work  might 
not  be  held  responsible  for  some  other  man's  statement. 

It  has  been  the  author's  aim  to  secure  accuracy,  but  in  a 
work  of  this  character  it  is  not  always  possible. 

An  effort  has  been  made  to  form  a  complete  bibliography. 
The  author,  however,  does  not  claim  that  it  is  exhaustive. 
The  literature  is  so  vast,  and  published  in  so  many  languages, 
that  many  papers  and  reports  may  have  been  overlooked  by 


PREFACE  IX 

the  compilers  of  the  various  indices.  Only  those  works  and 
reports  were  inserted  whose  titles  clearly  indicated  their  sub- 
ject matter. 

Too  many  writers,  unfortunately,  choose  obscure  titles  for 
their  works.  Then,  too,  some  writings  have  not  appeared 
in  the  kind  of  publications  in  which  one  would  naturally  ex- 
pect to  find  them. 

Some  reports  of  interest  are,  perhaps,  hidden  away  in  the 
proceedings  of  societies,  and  cHnical  reports  of  hospitals,  and 
have  never  reached  the  ordinary  channels  of  publicity. 

The  second  part  the  author  considers  the  most  important, 
because  his  experiments  have  cleared  up  certain  questions 
of  practical  importance,  and  settled  certain  details  of  surgi- 
cal technique.  All  original  experiments  blaze  the  way  for 
future  work. 

It  is  the  author's  hope  that  this  work  may  prove  helpful 
to  students,  and  that  it  may  be  the  incentive  for  greater  work 
on  this  subject. 

No  effort  was  made  to  collect  material  from  the  classical  or 
mediaeval  writers,  because  such  matter  would  be  valuable  only 
from  an  historical  standpoint.  It  is  the  author's  desire  to  pro- 
vide something  that  will  be  of  immediate  and  practical  benefit. 

The  author  wishes  to  commend  the  work  and  devotion 
of  Dr.  J.  S.  Wallingford  and  Dr.  T.  G.  Sellew  for  their  assist- 
ance in  the  experiments  upon  the  lung. 

He  also  desires  to  express  his  appreciation  of  the  devotion 
of  his  wife  in  correcting  this  manuscript. 

To  W.  H.  Wamsley,  Esq.,  he  is  very  grateful  for  many 
of  the  excellent  photomicrographs  used  in  this  work.  He  de- 
sires to  commend  the  work  and  devotion  of  Miss  Sadie  B. 
Helbert  in  arranging  the  bibliography,  and  those  of  Miss 
Bertha  Karl  in  handling  the  copy,  and  he  further  wishes  thank- 
fully to  acknowledge  the  many  courtesies  extended  to  him  by 
Mr.  Howard  Ayres  while  the  work  was  being  conducted  at 
the  University  of  Cincinnati. 


CONTENTS 


PART  I 


THE  SURGERY  OF   THE  HEART 

PAGE 

Preface vii 

Introduction 3 

Terminology 5 

CHAPTER 

I.    Anatomy  of  the  Heart 7 

II.    Experimental  Research 31 

III.  Cardiamorphia 40 

IV.  Ectocardia 77 

V.    Gunshot,  Lacerated,  and  Incised  Wounds      ...  91 

VI.    Cardioclasia 120 

VII.    Cardiorrhaphy — Cardiotomy— Heart  Sutures        .      .  146 

VIII.    Cardiac  Aneurysm 179 

IX.    Foreign  Bodies 189 

X.    Cardioliths 192 

XL    Calcification 198 

XII.    Abscess 202 

XIII.  Syphilitic  Gummata 206 

XIV.  Gangrene 212 

XV.    Benign  Tumors — Fibromata,     Lipomata,     Angeiomata, 

Rhabdomyomata,  Myxomata,  Polyps 213 

XVI.    Malignant  Tumors 223 

XVII.    Animal  Parasites— Par.\sitic  Fungi— Bacilli    .      .      .  227 

XVIII.    Experimental  Research  on  the  Heart  of  the  Dog    .  247 


Xll 


CONTENTS 


PART   II 


THE  SURGERY   OF   THE  LUNGS 

PAGE 

Introduction 275 

Terminology 279 

CHAPTER 

I.    Anatomy  of  the  Lung 282 

II.    Abnormalities 289 

III.  Experimental    Research    (i  795-1903) — Influence    op 

Trauma  on  the  Lungs  and  Heart 295 

IV.  History  of  Ligatures  and  Sutures 300 

V.     Pneumonotomy — Pneumonectomy — Pneumonorrhaphy— 

Pneumonopexy — Bronchotomy — General  and  Local 

Anaesthesia 308 

"Vl.    Gunshot,  Lacerated  and  Incised  Wounds       .      .      .  322 

VII.    Foreign  Bodies 341 

VIII.    Abscess — Bronchiectasis 358 

IX.    Gangrene 375 

X.    Rupture 386 

XL    Hernla 390 

XII.    (Edema 397 

XIII.  Polypi  in  the  Bronchia 402 

XIV.  Atelectasis  Apneumotosis 405 

XV.    Syphilis    . 411 

XVI.    Benign    Tumors  —  Lymphoma,    Chondroma,    Osteoma, 

Dermoid  Tumors 422 

XVII.    Malignant  Tumors— Sarcoma,  Carcinoma   ....  426 

XVIII.    Anthrax 437 

XIX.    Parasitic  Fungi— Actinomyces,    Aspergillus,     Pneu- 

monomyces,  Oidium 442 

XX.    Animal  Parasites: — Echinococcus,  Paragonimus    VVes- 

termani,  Cysticercosis,  Trichina  Spiralis           .      .  449 

Experimental  Research  on  the  Lungs  of  the  Dog    .  469 

XXI.    The  Lung  of  the  Dog 47^ 

Practical  Hints  and  Theoretical  Considerations,  De- 
duced and  Suggested  by  these  Experiments  .      .      .  474 

Description  of  Plates 484 

Record  of  Experiments 487 

Analysis  of  Tables 40 


LIST   OF    ILLUSTRATIONS 


PLATE 

I.    Anterior  view  of  heart  and  lung  of  dog  injected  in  situ,  Frontispiece 

Facing  page 
II.     Anterior  view  of  heart 3 

III.  Injected  section  of  heart  muscle  showing  ramifications  of  capil- 

laries among  the  muscular  fibres  and  how  they  appear  to 
pass  into  them. 
Longitudinal  section  showing  capillaries  and  muscular  fibres      .       10 

IV.  Longitudinal  section  of  the  cardiac  muscular  fibres  and  capil- 

laries. 
Longitudinal  section,  showing  muscular  fibres    ....       18 
V.     Transverse    section    of    cardiac   muscular  fibres,  showing  the 
capillaries  and  their  ramifications. 
Transverse  section  of  cardiac  muscular  fibres  showing   main 

blood-vessel  and  its  ramifying  capillaries      ....       28 
VI.     Transverse  section  of  cardiac  muscular  fibres  and  capillaries. 

Transverse  section  of  cardiac  muscular  fibres     ....       36 
VII.     Transverse  section  of  heart,  f  inch  from  apex. 

Transverse  section  of  heart,  ih  inches  from  apex      ...       46 
VIII.     Transverse  section  of  heart,  2J  inches  from  apex. 

Transverse  section  of  heart,  3  inches  from  apex       ...      56 
IX.     Transverse  section  of  heart,  45  inches  from  apex. 

Longitudinal  section  of  heart  dividing  the  right  and  left  heart      66 
X.     View  of  right  heart. 

Incision  in  right  ventricular  wall  showing  its  thickness      .         .       74 
XL     Anterior  view  of  left  heart  showing  incision  in  apex. 

Penetrating  incision  of  left  ventricular  wall  showing  its  thick- 
ness      84 

XII.     Showing  skewer  penetrating  the  two  ventricles  from   right   to 
left. 
A  direct  penetrating  knife  wound  of  left  ventricular  wall     .         .       94 


XIV 


LIST   OF   ILLUSTRATIONS 


PLATE 

XIII. 


XIV. 


XV. 

XVI. 

XVII. 

XVIII. 

XIX. 

XX. 

XXI. 

XXII. 

XXIII. 

XXIV. 

XXV. 

XXVI. 

XXVII. 

XXVIII. 

XXIX. 


XXX. 

XXXI. 

XXXII. 

XXXIII. 
XXXIV. 

XXXV. 


Facing  page 
An  oblique  f)enetrating  knife  wound  of  left  ventricular 

wall. 
A  longitudinal  penetrating  wound  of  the  heart  showing 

how  wounds  of  the  heart  may  be  extra-pericardial    .     104 
A  non-penetrating  transverse  gun-shot  wound  of  the  left 

ventricular    wall    dividing    the    anterior    coronary 

artery   and   vein 114 

Section  of  heart  muscle  showing  syphilitic  lesion    .        .124 

Fibromata 134 

Fibroid. — Lipoma 142 

Angeioma. — Myxomatous  tissue 150 

Myoma. — Rhabdomyoma 158 

Polypus 166 

Sarcomata,  giant  cell  and  spindle  cell    .        .        .        .172 

Sarcoma,  small  round  cell 180 

Carcinomata,  epithelial  and  deep-seated  ....     190 

Cysticercus  and  eggs  of  Cysticercus 200 

Cysticercus  (bladder  stage) 210 

Trichina  Spiralis,  encysted  in  human  voluntary  muscle, 

and  free 218 

Oidium. — Actinomyces 228 

Bacillus  (Edematis  Maligni. — Bacillus  Typhoides    .        .     236 
The  cross  represents  the  end  of  a  kangaroo  tendon  which 

was  used  to  ligate  the  left  coronary  artery  and  vein. 

(Experiment  No.  3,  page  263) 
The  cross  represents  the  end  of  a  silk  ligature  about  the 

anterior  coronary  vessels.     (Experiment  No.  6,  page 

264) 244 

Showing  silk  sutures  in  place.     (Experiments  Nos.  9  and 

10,  page  266) 254 

Showing  silk  sutures  in  place.    (Experiment  No.  11,  page 

266;  No.  12,  page  267) 262 

Showing  silk  sutures  in  place.     (Experiments  No.   16, 

page  269;  No.  18,  page  270) 270 

Anterior  view  of  human  lung 275 

Normal   human   lung;   anterior  view  showing  apex  of 

heart  and  tissues. — Posterior  view    .         .         .         .278 
Section  of  injected  human  lung,  showing  air  cells. 
Section  of  normal  human  lung 282 


LIST   OF   ILLUSTRATIONS 


XV 


PLATE 

XXXVI. 

XXXVII. 

XXXVIII. 

XXXIX. 

XL. 


XLI. 

XLII. 

XLIII. 

XLIV. 

XLV. 

XL  VI. 

XL  VII. 

XLVIII. 

XLIX. 

L. 

LI. 

LII. 

LIII. 

LIV. 

LV. 


LVI. 
LVII. 

LVIII. 

LIX. 

LX. 

LXI. 


Facing  page 
Section  of  normal  lung  of  a  water  dog  (Necturus  Later- 
alis) ...        .  •■ 286 

Sections  of  a  normal  lung  of  a  black  snake  .  .  .  290 
Sections  of  normal  lung  of  a  bird  (Martin)  .  .  .  296 
Sutures;   Whipstitch,  Herringbone    stitch,    Mattress,  or 

quilted,  stitch.  Bell  suture 300 

Sutures;  Combination  of  mattress  and  continued  stitches. 

Tug   stitch.    Combined   Tug   and  Tobacco   Pouch 

stitch.  Glover's   suture 

Anthracosis  in  cancerous  lung 


(Edema  of  lung — Polypus 

Lymphoma — Chondroma 

Osteoma — Dermoid  cyst  . 

Sarcomata,  small  round  cell  and  small  spindle  cell  . 

Sarcoma,  giant  cell. — Carcinoma,  epithelial    . 

Bacillus  Anthracis   (spores). — Bacillus   Aerogenes   Cap 
sulatus      

Bacillus  Friedlander  (acute  croupous  pneumonia). 

Pneumonia  (human  lung) 

Diplococcus  (Fraenkel). — Bacillus  Tuberculosis 

Actinomyces. — Aspergillus,  in  lung  of  cow  . 

Aspergillus  Fumagatus.     Mycelium  of  Aspergillus 

Pneumonomycosis 

Echinococcus. — Echincoccus,  advanced  stage 

Echinococcus. — Paragonimus  Westermani 

Paragonimus  Westermani  (from  lungs  of  a  hog),  i.  Sec- 
tion containing  a  lung  fluke  cyst  cut  open.  2.  Lung 
flukes,  natural  size.  3.  Contents  of  cyst  containing 
eggs  of  lung  fluke,  greatly  magnified  .... 

Lungs  of  a  hog  showing  cysts  caused  by  lung  flukes 

Posterior  view  of  heart  and  lungs  of  a  dog  injected  in  situ. 
(Description,  page  484) 

Transverse  section  of  the  lower  lobes.  (Description, 
page  484) 

Transverse  section  of  the  heart  and  lungs.  (Description, 
page  485) 

Posterior  view  of  transverse  section  of  the  heart  and  lungs. 
(Description,  page  485) 

Transverse  section  of  the  heart  and  lungs.  (Description, 
page  485)  .        .        .        .        , 


304 
310 

314 
318 

324 
328 

332 
338 

342 
348 

354 
360 

364 

370 
376 


380 
386 

388 
394 
398 
402 
408 


XVI 


LIST   OF   ILLUSTRATIONS 


PLATE 

LXIL 
LXIII. 

LXIV. 

LXV. 

LXVI. 

LXVII. 

LXVin. 

LXIX. 

LXX. 

LXXI. 

LXXIL 

LXXIIL 

LXXIV. 

LXXV. 

LXXVI. 

LXXVII. 

LXXVIIL 

LXXIX. 

LXXX. 

LXXXI. 

Lxxxn. 

LXXXIII. 

LXXXIV. 

LXXXV. 

LXXXVL 

LXXXVII. 


Facing  page 
Transverse  section  of  the  lungs.  (Description,  page  486)  412 
Posterior  view  of  transverse  section  of  the  lungs.     (De 

scription,  page  486) 
Experiment  No.  4,  page  487 


Experiment  No.  6,  page  488 

Experiment  No.  7,  page  488 

Experiment  No.  8,  page  488 

Experiment  No.  10,  page  489 

Experiment  No.  11,  page  489 

Experiment  No.  13,  page  489 

Experiment  No.  14,  page  489 

Experiment  No.  16,  page  490 

Experiment  No.  18,  page  490 

Experiment  No.  19,  page  490 

Experiment  No.  20,  page  491 

Experiment  No.  21,  page  491 

Experiment  No.  22,  page  491 

Experiment  No.  24,  page  491 

Experiment  No.  25,  page  491  (Pneumonopexy) 

Experiment  No.  26,  page  491 

Experiment  No.  27,  page  492 

Experiment  No.  28,  page  492 

Experiment  No.  30,  page  492 

Experiment  No.  31,  page  492 

Experiment  No.  ^^,  page  492 

Experiment  No.  34,  page  492 

Experiment  No.  46,  page  492 


416 
420 
424 
428 

430 
434 

438 
440 

444 
448 
45° 
452 
456 

458 
462 
466 
472 

474 
478 
482 
486 
488 
490 
492 
494 


PART    I 
THE    SURGERY   OF    THE    HEART 


Plate  II. 


Right  common  carotid  a 
Right  in1 

Right  subcia 
Right  vertel 

Right  subcia 
Right  inno 

Right  interna 

Superior 
Vena  azygos 

Right  pulm 
R.  pulmonary 


nferior  thyroid  veins 


Right  auri 


Right  auricul 


Pulmonary  artery 


Left  auricular  appendix 


Anth:rior  \'iew  of  the  Hkart 


(From  Deaver's  "Surgical  Anatomy.") 


PART    I 
THE    SURGERY    OF    THE    HEART 

INTRODUCTION 

Injuries  and  diseases  of  the  heart  have  resisted  surgery 
longer  than  almost  any  of  the  tissues  or  organs  of  the  human 
body.  They,  however,  no  longer  offer  such  resistance,  but 
find  themselves  subject  to  attack  on  the  same  surgical  prin- 
ciples as  other  parts  of  the  body.  The  recovery  of  twenty 
cases  out  of  fifty-six  penetrating  wounds  of  the  human  heart, 
after  having  been  closed  by  suture,  is  significant,  and  this, 
too,  all  having  been  done  since  1895.  The  object,  therefore,  of 
this  work  is  more  fully  to  demonstrate  by  the  cases  operated 
upon,  a  general  resume  of  injuries,  pathological  conditions, 
and  experimentation,  that  it  should  no  longer  be  exempt 
from  surgical  measures. 

The  chapter  on  anatomy  refers  to  both  the  human  and 
comparative  features  to  a  limited  degree,  and  of  necessity 
calls  for  a  consideration  of  abnormalities,  such  as  malposi- 
tions, displacements,  and  malformations,  each  of  which  has 
a  separate  chapter.  The  frequency  of  abnormalities  is  be- 
coming generally  known,  and  their  importance  in  cases  re- 
quiring surgical  intervention  better  appreciated.  Experi- 
mental research  bearing  directly  upon  the  surgical  aspect 
has  been  exceedingly  limited  as  compared  with  that  of  phys- 
iologic or  anatomic  research. 

Wounds  of  various  kinds  are  included  in  a  separate  chap- 
ter, that  the  character  of  wounds  most  amenable  to  surgery 

3 


4  THE   SURGERY   OF   THE   HEART 

might,  if  possible,  be  determined.  Aneurysm,  foreign  bodies, 
ossification  and  calcification,  together  with  abscess,  syphilis, 
and  gangrene,  possess  features  which  will  have  a  great  bear- 
ing upon  and  will  influence  the  future  surgical  work  on  the 
heart. 

The  application  of  surgical  principles  in  certain  cases  of 
aneurysm  of  the  heart  will,  no  doubt,  be  accomplished  by 
suture,  electrolysis,  or  the  injection  of  gelatine  or  something 
of  a  similar  character. 

The  removal  of  a  certain  class  of  foreign  bodies,  whether 
they  have  formed  within  or  have  entered  from  without,  should 
and  no  doubt  will,  be  accomplished.  That  a  cardiac  abscess 
should  be  incised  and  drained  there  can  be  no  doubt.  In 
a  selected  number  of  cases  the  application  of  carbolic  acid 
counteracted  with  alcohol  after  an  abscess  of  the  heart  has 
been  incised,  might  possibly  permit  of  closing  the  walls  of 
the  abscess  with  suture.  The  same  principles  might  be  suc- 
cessfully applied  to  cases  of  gangrene  of  the  heart. 

Tumors  of  a  pedunculated  variety,  on  the  external  sur- 
face, should  be  removed,  even  when  pedunculated  within  the 
cardiac  chambers,  their  removal  is  about  as  possible  and 
rational  as  the  removal  of  foreign  bodies  from  the  chambers 
of  the  heart. 

Parasitic  cysts  (animal  or  vegetable)  when  upon  the  ex- 
ternal surface,  or  in  the  wall  of  the  heart,  should  be  incised 
and  drained. 


TERMINOLOGY 

Acardia absence 

Acardiohaemia lack  of  blood 

Acardiotrophia atrophy 

Aerendocardia presence  of  air  in  the  heart 

Angeiocardiokinetic agents  stimulating  vessels  of  heart 

Angeiocarditis inflammation  of  heart  and  blood-vessels 

Atelocardia poor  development 

Cardiac  cycle a  complete  movement 

Cardiagra gouty  attack 

Cardialgia pain 

Cardianastrophe displaced  to  right 

Cardianeuria lack  of  nerve  stimulus 

Cardiant. affecting  the  heart 

Cardiarctia stenosis 

Cardiasthma dyspnoea 

Cardiatelia poor  development 

Cardiatrophia  1  t       h 

Cardiatrophy  j ^  ^ 

Cardiauxe enlarged 

Cardiectasis. ; dilatation 

Cardielcosis ulceration 

Cardiemphraxia obstruction  of  current 

Cardiocele hernia 

Cardiocentesis aspiration 

Cardioclsesia rupture 

Cardiocrystallus heart  crystal 

Cardiodemia fatty  degeneration 

Cardiography description 

Cardiohaemothrombus.  . .  heart  clot 

Cardiokinetic exciting  the  heart 

Cardiolith concretion  in  the  heart 

Cardiology anatomy,  physiology  and  pathology 

Cardiomalacia softening 

Cardiomegalia enlargement 

5. 


6  THE   SURGERY    OF   THE   HEART 

Cardiomorphia malformed 

Cardiopalmus palpitation 

Cardiopathy disease 

Cardiopericarditis inflammation  of  heart  and  pericardium 

Cardioplegia paralysis 

Cardioptosis downward  displacement 

Cardiorrhexis rupture 

Cardiosclerosis hard 

Cardiostenosis constriction 

Cardiotomy dissection 

Cardiotoxis poison 

Cardiotrauma injury 

Cardiovascular pertaining  to  blood-vessels 

Carditis inflammation 

Carditopography topographical  anatomy 

Dexicardia     "| 

Dexiocardia    V to  right 

Dextrocardia  j 

Ectocardia       1 abnormality  of  position 

Ectopia  cordis  j 

Hajmatolysis imperfect  coagulate 

Hccmatomyces fungus 

Hajmatopericardium blood  in  pericardium 

Haematophyte vegetable  organism 

Haematoxin blood  poison 

Ha^matozoon animal  organism 

Ha^mocardiorrhagia haemorrhage  of  heart 

Hemicardia one  auricle;  one  ventricle 

Monocardium a  single   chambered  heart,  or  one   not 

completely  divided 

Mycosis pathological  mycosis 

Orthodiagraphy X-ray  picture  of  the  heart 


CHAPTER  I 

ANATOMY    OF    THE    HEART 
(HUMAN   AND   COMPARATIVE) 

The  embryonic  heart  of  the  lower  vertebrates  differs 
both  in  form  and  origin  from  the  heart  of  the  higher  verte- 
brates. In  some  of  the  lower  vertebrates  the  heart  never 
develops  much  beyond  the  embryonic  stage.  This  form  per- 
sists throughout  life.  Anomalies  of  the  human  heart  are 
very  often  only  cases  of  arrested  development  of  the  embry- 
onic heart.  This  arrest  may  occur  at  any  stage,  hence 
anomalies  of  the  human  heart  may  show  any  of  the  embryonic 
forms.  The  heart  is  the  first  permanent  organ  of  the  embryo 
to  take  up  its  functional  activity.  In  its  earliest  forms  it  pre- 
sents the  characteristics  of  the  central  impelHng  tube  of  the 
invertebrates,  which  is  functionally  analogous  to  the  heart  of 
the  vertebrates.  This  impelling  tube  of  the  invertebrates  is 
a  very  simple  mechanism  to  perform  its  office.  The  arteries 
empty  into  the  anterior,  and  the  veins  into  the  posterior  ex- 
tremity. 

One  school  of  evolutionists  points  to  the  development  of 
the  mammahan  heart  as  proof  of  their  dictum,  that  the  em- 
bryo of  the  vertebrates  presents  at  various  stages  of  its  de- 
velopment the  characteristics  of  the  adult  heart  of  all  the 
lower  forms. 

At  first  the  heart  of  the  human  embryo  is  exactly  similar 
to  the  invertebrate  heart  described  above.  Then  it  takes 
the  form  typical  of  that  of  the  fish,  i.e.,  an  organ  of  three 
cavities,  a  simple  auricle,  a  simple  ventricle,  and  a  bulbus 

7 


8  THE   SURGERY   OF   THE   HEART 

arteriosus  at  the  origin  of  the  aorta.  The  subdivision  of  the 
aorta  into  four  or  five  arches  resembles  the  entrances  of  the 
gill-cavities  of  the  cartilaginous  fish.  This  form  of  circulat- 
ing apparatus  is  common  to  all  vertebrates,  at  least  in  the 
earliest  stage  of  their  development.  This  is  the  permanent 
form  in  fish,  although  in  some  there  is  further  development 
of  the  vascular  system. 

Irr  the  higher  vertebrates  the  plan  of  circulation  is  totally 
changed,  because  of  the  formation  of  new  cavities  in  the  heart 
and  the  formation  of  new  vessels.  Hence  it  is  not  strictly 
correct  to  speak  of  the  vascular  arches  in  their  necks  as 
branchial  arches,  since  no  branchiae,  or  gills,  are  ever  devel- 
oped. The  highest  pair  of  the  so-called  branchial  arches, 
by  union  of  the  aortic  trunk,  help  to  form  the  subclavian  and 
carotid  arteries,  the  middle  pair  undergo  the  greatest  change, 
the  right  becomes  obliterated  and  the  other  becomes  the 
"  arch  of  the  aorta." 

Many  of  the  anomalies  of  arteries  and  veins  can  also  be 
explained  as  arrested  development  in  the  embryonic  state. 

In  birds  and  the  lower  mammals  there  are  two  venae  cavae 
superiores.  At  the  birth  of  the  human  foetus  there  is  a  change 
in  the  plan  of  circulation  on  account  of  the  cessation  of  placen- 
tal circulation.  With  the  first  breath  of  the  new-born  an  im- 
mense quantity  of  blood  is  transmitted  to  the  lungs.  In  a 
short  time  the  ductus  venosus  and  ductus  arteriosus  shrivel 
up  and  become  mere  ligaments;  at  this  time  the  foramen 
ovale  becomes  closed  by  its  valve.  The  circulation,  which 
had  been  reptilian  in  character,  now  becomes  of  the  perma- 
nent form  found  in  birds  and  mammals. 

The  heart  of  the  dugong  is  so  deeply  cleft  from  apex  to 
base  as  to  seem  two  separate  organs.  The  same  condition 
is  found  in  the  human  foetal  heart  at  a  very  early  period. 

In  man  the  vena  porta  is  analogous  to  the  aorta  of  the 
fish.  This  shows  that  it  is  properly  regarded  as  arterial  in 
character.    It  bears  the  same  relation  to  the  general  circula- 


ANATOMY    OF   THE    HEART  9 

tion  in  man  that  the  respiratory  circulation  in  the  Mollusca 
and  Crustacea  does  to  the  general  circulation  of  these  orders. 
The  mammalian  heart  may  be  described  as  an  organ  whose 
functions  are  those  of  a  pumping-engine  to  propel  blood 
through  the  body. 

The  human  heart  is  an  oval  or  pear-shaped  organ,  three 
to  five  inches  wide  and  three  to  four  inches  thick,  weighing 
nine  to  seventy-two  ounces,  rarely  above  twenty-five  ounces, 
normally  nine  to  twelve  ounces  in  the  male  and  seven  to  ten 
ounces  in  the  female. 

The  broadest  part  of  the  heart,  called  the  base,  is  directed 
upward  and  backward  and  to  the  right,  extending  from  the 
level  of  the  fifth  dorsal  vertebra  to  the  eighth,  (Heath  says 
from  the  sixth  to  the  ninth.) 

The  apex,  or  pointed  end,  of  the  heart  can  be  felt  between 
the  fifth  and  sixth  ribs,  a  little  below  the  inner  side  of  the 
left  nipple.  (Ouain  says  three  and  one-quarter  inches  from  the 
middle  line  of  the  sternum  and  one  and  one-half  inches  below 
the  nipple.)  The  margins  of  the  lungs  cover  all  but  a  small 
part  of  the  heart.  This  part  of  the  heart  left  uncovered  is 
part  of  the  right  ventricle,  is  irregular  in  outline  and  about 
two  inches  square  in  area.  The  heart  has  four  cavities,  the 
right  and  left  auricles  in  the  base,  and  the  right  and  left  ven- 
tricles toward  the  apex.  It  may  be  considered  as  a  double 
heart,  keeping  in  mind  the  typical  heart  of  two  cavities 
found  in  the  lower  orders. 

Like  the  lungs,  and  other  important  organs,  the  heart 
has  a  separate  individual  envelope  known  as  the  pericardium. 
Normally  the  pericardium  conforms  to  the  general  shape  of 
the  heart  reversed.  It  is  pyriform  in  outline  with  the  small 
end  uppermost ;  the  base  rests  upon  the  diaphragm.  It  is  con- 
tinued above  to  cover  the  great  vessels  of  the  heart,  and 
connects  with  the  deep  cervical  fascia  at  a  height  of  two 
inches  above  the  origin  of  these  vessels. 

The  four  cavities  of  the  heart  approximate  one  another  in 


lO  THE  SURGERY  OF  THE  HEART 

size.  The  contents  of  each  cavity  are  about  three  ounces. 
The  auricles  will  hold  a  fraction  less.  The  walls  of  the  left 
ventricle  are  much  thicker  than  those  of  the  right.  This  is 
undoubtedly  in  compensation  for  the  greater  work  that  it 
has  to  perform. 

It  has  been  found  experimentally  that  the  left  ventricle 
contracts  with  more  than  double  the  force  of  the  right.  The 
walls  of  the  left  ventricle  are  nearly  three  times  as  thick  as 
those  of  the  right.  All  this  is  in  agreement  with  the  laws 
of  mechanics,  since  the  left  ventricle  has  far  greater  arterial 
resistance  to  overcome. 

In  regard  to  the  capacity  of  the  cavities,  it  has  been  noted 
that  the  ventricles  receive  more  blood  from  the  auricles  than 
the  latter  could  transmit  by  simply  emptying  themselves 
once.  If  three  ounces  be  taken  as  the  capacity  of  the  ventri- 
cle, and  eighteen  pounds  the  weight  of  the  blood  in  the  body 
of  an  average  sized  man,  it  will  require  ninety-six  strokes 
to  force  the  whole  amount  of  blood  through  either  side.  If 
seventy-two  pulsations  per  minute  be  taken  as  the  average, 
it  will  require  one  and  one-third  minutes  for  a  given  particle 
to  return  to  a  given  point,  that  is,  if  it  was  not  sent  else- 
where. 

It  is  not  only  interesting,  but  of  great  practical  impor- 
tance, to  consider  the  mechanism  of  the  heart  and  circula- 
tion in  the  various  orders  of  vertebrates,  for  by  such  study 
a  more  thorough  understanding  of  the  human  cardiac  and 
circulatory  apparatus  can  be  obtained.  This  comparative 
study  also  throws  light  upon  some  of  the  seemingly  inex- 
plicable human  anomalies. 

Comparative  Anatomy The  ventricles  of  the  heart  are  but 

imperfectly  divided  in  the  class  Reptilia,  except  the  crocodil- 
ian group,  in  which  they  are  completely  divided.  In  some 
of  the  Chelonians  the  communication  between  the  auricles 
is  permanent.  The  fossa  ovalis,  which  represents  the  primi- 
tive division  of  the  heart,  is  more  completely  obliterated  in 


Plate  III. 


X  100. 
Injected  Section  of  Heart  Muscle  Showing  Rami- 
fications OF  Capillaries  Among  the  Muscular 
Fibres  and  How  They  Appear  to  Pass 
Into  Them.      (Dr.   A.  V.   Meigs.) 


X  300. 

Longitudinal    Section     Showing     Capillaries 
Muscular  Fibres.     (Dr.  A.  Y.  Meig-s.) 


AND 


(Anatomy  of  the   Heart.) 


ANATOMY   OF   THE   HEART  II 

the  kangaroo  than  in  man.  In  those  Batrachians  which  have 
but  a  single  ventricle  the  root  of  the  aorta  is  dilated  into  a 
bulbous  aorta  or  biilbus  arteriosus.  The  latter  is  rhythmically 
contractile  in  the  Elasmobranchii,  but  not  in  the  Teleosteans. 

Where  the  heart  consists  of  but  two  cavities,  one  auricle 
and  one  ventricle,  as  in  fishes,  the  root  of  the  aorta  is  dilated 
into  a  bulbus  arteriosus,  and  the  venous  channels  terminate 
at  the  heart  in  a  sinus  venosus. 

The  heart  of  the  lancelet  consists  of  but  a  single  tube. 
The  cavity  of  the  pericardium  is  continuous  with  that  of  the 
peritonaeum  in  the  Myxinoid  fishes  and  Elasmobranchii.  The 
crocodiHan  heart  gives  rise  not  only  to  the  pulmonary  artery, 
but  also  to  the  aortic  arch.  In  frogs  and  most  of  the  reptiles 
a  special  arrangement  of  valves  is  provided  for  the  propul- 
sion of  the  venous  blood  into  the  pulmonary  arteries,  and 
the  arterial  blood,  for  the  most  part,  into  the  aortic  arches. 
These  groups  have  pulmonary  arteries  coexisting  with  a  sin- 
gle or  an  imperfectly  divided  ventricle.  The  apex  of  the  heart 
of  the  dugong  is  deeply  notched;  this  fact  can  be  detected 
externally.  The  heart  of  birds  is  more  elongated  than  the 
human  heart,  while  that  of  the  Chelonian  is  shorter  and 
broader.  In  Amphioxus,  the  simple  vesicular  heart  is  con- 
tinued forwards  preaxially,  into  a  median  artery,  whence  on 
each  side  diverge  very  many  pairs  of  arteries.  The  same 
condition  is  found  amongst  the  vertebrates  in  the  lancelet. 
In  no  other  member  of  that  sub-kingdom  can  aortic  arches 
by  any  calculation,  or  at  any  period  of  life,  be  found  to  ex- 
ceed eleven  on  each  side.  (St.  George  Mivart,  "Elementary 
Anatomy.") 

Amongst  sharks  the  genus  Heptanchus  have  probably 
seven  distinct  branchial  arches  on  each  side.  In  the  Lepido- 
sirens  and  Ceratodus  there  are  five  branchial  arches  on  each 
side;  the  perch  has  but  four.  In  the  frog,  at  that  period  of  its 
tadpole  stage  when  the  gills  begin  to  atrophy,  three  branch- 
ial arteries  coexist  with  the  three  corresponding  vessels  going 


12  THE  SURGERY  OF  THE  HEART 

to  the  dorsal  aorta.  At  this  time  there  is  direct  communi- 
cation between  neighboring  arteries  and  veins,  although  each 
artery  and  vein  minutely  divides  in  the  gill  beyond  the  points 
of  communication.  In  the  adult  frog  there  is  no  breaking 
up  of  the  aortic  arches  by  any  interposed  ramifications. 

At  an  early  age  of  his  existence  man  possesses  a  ductus 
arteriosus  connecting  the  pulmonary  artery  with  the  aorta. 
In  Cryptobranchus  this  connection  is  permanent  and  on  both 
sides  of  the  body. 

The  crocodile  has  two  aortic  arches,  each  ventricle  giv- 
ing off  one.  The  two  common  carotids  and  the  right  sub- 
clavian originate  in  one  trunk  in  the  Hon.  The  hedgehog  has 
two  innominate  arteries.  The  two  common  carotids  in  birds 
ascend  in  close  juxtaposition.  One  of  these  is  sometimes 
much  reduced  in  size,  or  even  aborted.  The  vertebral  artery 
in  the  llamas  perforates  the  neural  laminae  instead  of  pass- 
ing through  the  cervical  transverse  processes.  Birds  have 
a  primitively  double  aortic  arch  springing  from  the  left  ven- 
tricle, but  only  the  right  half  develops  into  the  permanent 
form.  It  is  the  left  half  of  this  primitively  double  arch 
which  is  developed  in  mammals. 

The  great  arteries  which  supply  the  head  and  forelegs 
originate  in  common  from  the  aorta  as  one  great  trunk.  But 
in  the  dugong  all  the  great  arteries  which  supply  the  head, 
et  caetera,  have  each  a  separate  origin  arising  from  the  aorta. 
In  the  domestic  ox,  the  internal  carotid  breaks  up  inside  of  the 
skull  into  a  network  of  small  arteries,  I'ctc  niirabilc. 

There  are  differences  in  the  proportions  existing  between 
the  external  and  internal  carotids,  and  also  variations  in  the 
course  taken  by  each  which  characterize  different  groups  of 
mammals.  In  the  sloths  and  slow  lemurs,  the  branchial  artery 
breaks  up  into  a  number  of  branches  running  side  by  side. 
The  femoral  arteries  in  the  same  animals  and  also  among  the 
Echidna  are  similarly  divided.  In  some  of  the  Cetacea  (por- 
poise), the  intercostal  arteries  form  great  convoluted  rctia 


ANATOMY   OF   THE   HEART  I3 

viirabilia.  In  the  osseous  fishes  and  in  the  Lepidosiren,  a 
small  rete  mirahile  is  developed  from  the  first,  or  hyoidean, 
aortic  arch.  In  many  fishes  there  is  a  less  number  of  inter- 
costal arteries  than  intercostal  spaces :  in  this  class  of  animals 
the  arter}-  of  the  pectoral  limb  is  given  oft  from  the  dorsal 
aorta  immediately  after  its  formation. 

The  dorsal  arten,-  dilates  beneath  each  vertebral  centrum 
of  the  abdomen  in  the  carp.  In  fishes  this  artery  gives  off 
many  small  branches  to  the  kidneys. 

The  internal  iliac  arteries  do  not  share  with  the  external 
in  a  common  origin.  The  middle  sacral  arten.-  continues 
much  farther  and  is  of  larger  size  in  the  kangaroo  than  in 
other  vertebrates,  the  internal  iliacs  are  larger  than  the  ex- 
ternal and  the  inferior  mesenteric  artery  is  aborted. 

A  rctc  mirahile  is  formed  in  the  Porbeagle  shark  by  the 
ramifications  of  the  cceliac  arteries. 

In  one  point  there  is  a  great  difference  between  arteries 
and  veins.  Excluding  rdia  mirahilia  and  all  gill  structures,  it 
will  be  found  that  the  arteries  never,  after  dividing,  reunite 
to  form  second  aggregations.  But  the  veins  do  break  up 
and  reunite  to  form,  so  as  to  speak,  a  new  system.  The  so- 
called  portal  circulation  is  thus  formed.  The  portal  veins 
break  up  into  a  minute  network  in  the  liver,  and  then  gradu- 
ally reunite  to  form  the  hepatic  veins  which  carry  the  blood 
to  the  heart. 

The  venous  rctc  mirahile  attains  its  maximum  in  the  ab- 
dominal region  of  the  porpoise.  The  two  azygos  are  equal. 
or  nearly  so  in  the  monotremes.  Rabbits  have  two  superior 
vencB  cavcB.  Each  of  these  opens  into  the  right  auricle  by 
a  separate  and  distinct  aperture.  The  middle  sacral  vein  is 
greatly  increased  in  size  and.  of  course,  in  importance  in  the 
Cetacea.  all  of  this  class  having  a  ver\-  large  coccygeal  region. 

The  veins  of  the  caudal  region  and  the  pelvic  limbs  enter 
the  kidney  in  the  Batrachians  and  there  form  a  network. 
These  ramifications  reunite  on  emerging  from  the  kidney  to 


14  THE  SURGERY  OF  THE  HEART 

form  a  new  trunk  to  carry  the  blood  to  the  heart.  Thus  in 
this  class  there  is  a  tertiary  distribution  of  blood  in  the  kidney, 
similar  to  the  secondary  or  portal  circulation  in  man.  The 
abdominal  veins,  however,  go  directly  to  the  liver  and  do  not 
help  to  form  this  renal  circulation.  The  abdominal  veins  of 
birds  go  directly  to  the  vena  cava  inferior.  In  most  Batra- 
chians  and  reptiles  the  great  veins  dilate  into  a  rhythmically 
contractile  siuiis  vcnosus. 

The  permanent  venous  system  of  fish  is  exactly  repro- 
duced in  the  human  embryo.  Fish  have  two  cardinal  veins 
uniting  to  form  a  ductus  Ciivieri  which  empties  into  a  sinus 
vcnosus  at  the  heart.  The  veins  themselves  are  contractile  in 
certain  groups.  The  portal  vein  of  Thyxine  contracts  rhyth- 
mically; the  eel  possesses  a  pair  of  small  contractile  vesicles 
on  its  caudal  vein ;  in  the  limbs  of  many  Batrachians  the  root 
veins  are  contractile;  the  veins  which  traverse  the  membranes 
of  the  wings  of  bats  are  similarly  contractile;  and  Amphioxus 
is  sui  generis  in  this  regard,  as  in  many  other  points.  Not 
only  is  the  portal  vein  contractile,  but  many  veins  of  lesser  im- 
portance also  possess  this  property.  The  veins  of  the  Cetacea 
have  no  valves. 

In  fish  and  young  batrachians,  the  blood  is  not  propelled 
in  a  double  circuit  as  in  man,  but  makes  a  single  great  cir- 
cuit, only  returning  to  the  heart  when  the  whole  round  has 
been  completed.  In  this  case  only  venous  unaerated  blood 
is  propelled  by  the  heart.  The  blood  leaves  the  heart  by  the 
bulbous  aorta,  passes  to  the  gills,  where  it  is  aerated.  This 
aeration  is  accomplished  by  the  reception  of  oxygen  from  the 
particles  of  air  mechanically  mixed  up  with  the  water  in 
which  the  animals  Hve. 

All  air-breathing  vertebrates  like  man  possess  two  circu- 
lations; that  is,  part  of  the  blood  returns  to  the  heart,  before 
being  distributed  to  the  body  generally;  but  both  venous  and 
arterial  blood  are  more  or  less  mixed  up  in  the  heart  itself 
in  all  batrachians,  and  in  such  cases  the  aortic  arches  propel 


ANATOMY   OF   THE    HEART  1 5 

an  impure  fluid.  The  arrangement,  structure,  and  mechanism 
of  both  the  chambers  of  the  heart  and  aorta  are  so  complex 
that  the  mixture  of  the  venous  and  arterial  blood  is  incom- 
plete. Nearly  all  the  blood  from  the  lungs  is  forced  into 
the  aortic  arch,  which  supplies  the  anterior  portion  of  the 
body.  This  process  is  found  also  in  some  still  lower  orders, 
as  in  the  common  frog. 

Although  the  two  states  of  the  blood  are  strictly  divided 
between  the  two  sides  of  the  heart  in  crocodiles,  yet  the  blood 
in  the  circulation  is  impure.  This  is  because  of  the  communi- 
cation between  the  two  aortic  arches  after  leaving  the  heart. 
In  the  perch,  the  blood  carried  to  the  gills  can  enter  the  dorsal 
aorta  only  by  means  of  the  capillaries  of  the  gills.  There  is 
a  complete  continuity  of  each  arch  from  the  heart  to  the 
dorsal  aorta  in  the  embryo  of  the  fish.  In  the  Lepidosiren 
and  Monopterus  this  condition  persists  throughout  Hfe. 

Certain  lesions  of  the  heart  cannot  be  diagnosticated  un- 
til constitutional  disturbances  are  produced.  But  the  same 
lesion,  even  in  the  same  person,  need  not  produce  the  same 
constitutional  disturbances.  It  is  essential  in  all  heart  lesions 
which  might  be  benefited  by  surgical  treatment,  that  the 
cause  be  discovered  early.  The  patient  who  undergoes  any 
cardiac  surgical  operation  requires  all  the  strength,  vitality 
and  resistance  possible  successfully  to  withstand  the  shock. 
The  same  may  be  said  of  operations  on  any  of  the  internal 
viscera.  Because  of  the  lack  of  knowledge  of  the  pathologi- 
cal physiology  of  the  viscera,  and  especially  because  of  the 
uncertainty  surrounding  the  pathological  physiology  of  the 
heart,  this  and  correlated  subjects  are  taken  up  much  more 
fully  than  is  usual  in  a  work  of  this  character. 

The  pericardium  consists  of  two  layers,  a  fibrous  and  a 
serous  layer.  The  fibrous  layer  is  a  dense  membrane  which 
is  attached  to  the  diaphragm.  Eight  tubular  sheaths  are 
formed  from  the  superior  portion  of  the  pericardial  sac  for  the 
great  vessels  at  the  base  of  the  heart.     The  serous  layer  is 


l6  THE  SURGERY  OF  THE  HEART 

formed  into  a  closed  sac.  The  muscular  tissue  of  the  heart  is 
similar  to  the  ordinary  striped  or  voluntary  muscle.  There  are 
both  longitudinal  and  transverse  striations.  Each  individual 
fibre  consists  of  a  number  of  muscular  elements.  The  latter 
consists  of  a  nucleus,  and  a  film  which  presents  the  appearance 
of  granular  protoplasm.  This  nucleus,  in  which  is  found  an 
intranuclear  plexus,  together  with  the  thin  film,  constitute 
what  Max  Schultze  calls  the  muscle  corpuscle.  Each  of 
these  so-called  muscle  corpuscles  is  surrounded  by  a  mass 
of  that  material  which  seems  to  be  the  functionally  active  part 
of  the  heart  substance.  The  ends  of  each  individual  muscle 
element,  which  are  serrated  or  bifurcated,  dovetail  into  a  sim- 
ilarly formed  end  of  another  element.  These  elements  are 
cylindrical  in  shape.  Each  fibre  is  made  up  of  several  of 
these  muscle  elements  united,  and  because  these  elements 
do  not  always  unite  end  to  end,  but  laterally  and  otherwise, 
thus  there  is  produced  the  reticulated  appearance  of  a  sec- 
tion of  the  heart.  In  elderly  persons  a  golden  yellow  or  brown 
pigment  is  sometimes  found  at  the  poles  of  the  nuclei  of  the 
muscle  corpuscles. 

The  interstices  of  muscular  network  are  filled  by  a  highly 
vascular  connective  tissue,  which  is  in  direct  contact  with 
the  muscular  elements. 

If  the  human  heart  be  removed  very  soon  after  death, 
the  inner  surface  of  the  endocardium  will  be  seen  to  con- 
sist of  a  single  layer  formed  of  nucleated  endothelial  cells, 
flattened.  Beneath  this  endothelial  layer  there  is  a  reticu- 
lated stratum,  also  formed  of  flattened  cells,  which,  how- 
ever, are  branched.  Trabecul^e  run  from  this  layer  into  the 
connective  tissue  found  between  the  muscle  fibres.  In  the 
substance  of  this  network  of  cells,  are  minute  muscular  bands 
analogous  to  those  in  the  myocardium.  A  stratum  of  elastic 
tissue  lies  beneath  this  layer  of  network  disposed  cells. 

Numerous  arteries  and  veins  are  found  on  the  surface 
of  the  heart.     All  of  these  vessels  are  of  ordinary  structure. 


ANATOMY    OF   THE   HEART  I7 

Within  the  walls  of  the  heart,  only  the  veins  of  large  size  have 
three  coats.  The  walls  of  the  smaller  veins  are  composed 
of  a  single  layer  only  of  endothelium.  In  other  words,  the 
smaller  veins  running  through  the  heart's  walls  are  identical 
in  structure  with  the  capillaries. 

The  structural  composition  of  the  walls  of  the  arteries 
within  the  substance  of  the  heart  is  normal,  i.e.,  three  coats. 
There  is  one  peculiarity  characteristic  of  the  cardiac  arteries. 
This  refers  to  the  way  in  which  the  arterioles  become  merged 
into  capillaries.  The  number  of  efferent  capillaries  is  greater 
than  the  number  of  afferent.  The  capillaries  run  in  all  direc- 
tions among  the  muscular  fibres.  As  A.  V.  Meigs  says: 
"  The  capillaries  not  only  enter  the  muscular  fibres,  but  also 
actually  penetrate  to  their  very  centres."  ("  Origin  of  Dis- 
ease," Philadelphia,  1899;  p.  65.) 

"  The  superior,  middle,  and  inferior  cervical  ganglia  form 
the  cerebro-spinal  nerves  of  the  heart."  The  above  mentioned 
ganglia  are  of  the  sympathetic  and  form  no  part  of  the  cerebro- 
spinal system.  From  them  we  have  the  superior,  middle,  and 
inferior  sympathetic  cardiac  nerves  given  off.  These  enter  the 
thoracic  cavity,  and  uniting  with  branches  of  the  pneumo- 
gastric,  form  the  cardiac  plexus.  Therefore,  the  pneumogas- 
tric  is  the  cerebro-spinal  nerve,  and  the  cardiac  branches  from 
the  superior,  middle,  and  inferior  cervical  ganglia  are  sym- 
pathetic. From  the  plexus  thus  formed  by  the  pneumogastric 
and  sympathetic,  cardiac  branches  are  distributed  to  the  heart." 

W.  E.  Lewis. 

The  structure  of  the  veins  within  the  walls  of  the  heart 
proves  that  nature  has  made  abundant  provision  for  its 
nourishment.  The  veins,  very  probably,  participate  largely 
in  the  nutrition  of  the  cardiac  tissues  and  furnish  the  means 
of  transportation  of  waste  material ;  because  of  their  distensi- 
bility  they  may  act  the  role  of  reservoirs. 

These  peculiarities  in  structure  of  the  heart  have  an  im- 


l8  THE  SURGERY  OF  THE  HEART 

portant  bearing  in  the  production  of  the  cardiac  movements. 
It  is  only  in  the  light  of  these  peculiarities  that  the  mechan- 
ics of  the  heart-beat  becomes  comprehensible.  An  intimate 
acquaintance  with  the  nervous  mechanism  of  the  heart  is  of 
even  greater  importance.  Branches  from  the  superior  cervi- 
cal ganglion,  middle  cervical  ganglion,  and  of  the  inferior 
cervical  ganglion  form  the  cerebro-spinal  nerves  of  the  heart. 
The  glosso-pharyngeal,  pneumogastric,  hypoglossal,  and  the 
first  cervical  nerves  also  originate  in  the  superior  cervical 
ganglion.  The  cardiac  cerebro-spinal  nerve  originates  in 
the  middle  cervical  ganglion,  and  is  placed  in  communica- 
tion with  the  fifth  and  sixth  cervical  nerves  at  its  origin. 
These  connections  must  be  kept  in  mind  in  order  to  demon- 
strate how  and  why  the  heart  is  influenced  so  profoundly 
by  lesions  of  other  organs  and  tissues. 

Peripheral  branches  of  the  above  mentioned  cervical 
ganglia,  and  sometimes  also  a  branch  from  the  first  thoracic 
nerve,  by  their  union  with  the  cardiac  branches  of  the  pneu- 
mogastric, form  the  intricate  plexus  cardiaciis  around  the  base 
of  the  heart,  under  the  arch  of  the  aorta.  Usually  these 
branches  divide  into  two  portions:  The  superficial  portions 
lie  in  front  of  the  aorta,  and  the  deeper  portions  lie  behind 
and  below  the  aorta.     The  latter  portions  are  the  largest. 

The  walls  of  the  heart  are  pierced  by  filaments  from  the 
plexus  cardiacus.  On  the  nerves  as  they  ramify  through  the 
heart  are  many  microscopic  ganglia.  Wrisberg's  ganglion 
in  the  centre  of  the  plexus  cardiacus  plays  the  most  important 
part  of  these  ganglia.  In  some  of  the  lower  orders  these 
ganglia  have  been  proven  to  perform  the  special  function 
of  regulating  and  controlling  the  functions  of  the  heart.  In 
these  orders,  they  have  the  power  to  insure  the  continuance 
of  the  heart-beat,  even  after  the  connection  between  the 
h^art  and  the  central  nervous  system  of  these  animals  has 
been  severed. 

The   pneumogastrics   or   vagi    are    the    most    important 


Plate    IV. 


X  100. 

Longitudinal  Section  of  Cardiac  ^Muscular  Fibres 
AND  Capillaries.     (Dr.  A.  V.  IMeigs.) 


X   100. 

Longitudinal    Section    Showing   Muscular    Fibres. 
(Dr.  A.  V.  Meigs.) 


(Anatomy  of  the  Heart.) 


ANATOMY    OF   THE   HEART  1 9 

nerves  in  the  body.  They  are  the  only  cranial  nerves  abso- 
lutely essential  to  life.  If  both  vagi  be  severed,  death  will 
follow  in  a  few  hours.  The  connection  between  the  pneu- 
mogastric  and  the  sympathetic  system  is  exceedingly  inti- 
mate. In  some  of  the  lower  orders  of  the  animal  kingdom 
it  performs  the  functions  of  the  sympathetic,  and  in  others 
it  takes  the  place  of  the  sympathetic.  It  is  what  may  be 
termed  a  double-acting  nerve,  since  it  possesses  both  motor 
and  sensory  activities.  These  impulses  are  transmitted  to 
the  heart  by  separate  systems  of  nerve  fibres;  centrifugal 
impulses  which  slow  the  heart-beat  over  one  set  of  fibres, 
and  over  the  other  centripetal  impulses  pass  which  influence 
the  heart's  movements  by  reflex  action.  The  pneumogas- 
trics  are  closely  connected  with  many  nerves  of  the  cerebro- 
spinal system.  They  anastomose  -immediately  after  their 
exit  with  the  neighboring  nerves,  and  pneumogastrics  and 
sympathetic  unite  with  both  the  hypoglossal  and  glosso- 
pharyngeal nerves.  The  vagus  has  a  recurrent  branch  which 
goes  to  the  dura  mater. 

Some  scientists  hold  that  the  hypoglossal  is  simply  a 
coalescence  of  the  anterior  roots  of  the  vagus.  In  some  of 
the  mammalia  and  in  embryos  it  has  a  posterior  root  and  a 
ganglion  of  its  own.  It  is  believed  by  many  comparative 
anatomists  that  the  hypoglossal  is  formed  by  the  coalescence 
of  certain  spinal  nerves,  three  in  number,  found  in  certain 
of  the  lower  orders  of  animals,  but  not  found  in  man,  in  any 
stage  of  existence. 

Many  experimenters  have  attempted  to  discover  the 
exact  function  of  the  vagus,  at  least  in  regard  to  the  cardiac 
movements,  but  there  is  still  much  uncertainty  surround- 
ing the  subject.  A  nerve  centre,  situated  in  the  floor  of  the 
fourth  ventricle,  produces  normally  similar  effects  to  those 
caused  by  irritating  the  vagus. 

The  cardiac  ganglia  previously  mentioned  are  not  only 
found  deep  within  the  cardiac  tissues,  but  are  numerously 


20  THE  SURGERY  OF  THE  HEART 

scattered  over  the  walls  of  the  heart  just  beneath  the  ex- 
ternal surface.  It  is  claimed  that  the  injury  of  any  one 
of  these  ganglia  results  in  instant  death.  This  explains  the 
cause  of  the  almost  instantaneous  deaths  in  many  cases  of 
cardiac  wounds.  It  also  shows  why  cardiac  surgery  must 
be  always  a  formidable  undertaking. 

There  is  another  cause  for  caution  in  suturing  or  incis- 
ing the  heart  in  that  the  external  cardiac  blood-vessels  are  so 
highly  elevated  above  the  surface  of  the  heart.  The  coro- 
nary arteries  are  raised  to  a  relatively  great  height  above  the 
exterior  surface  of  the  heart.  Each  artery  is  accompanied 
by  the  corresponding  vein.  These  blood-vessels  branch  in 
almost  regular  order,  and  the  branches  are  thrown  off  at 
almost  right  angles  to  the  main  vessels.  Whenever  an  artery 
branches,  the  accompanying  vein  also  does  the  same,  but 
there  is  a  slight  distance  between  the  places  of  division. 

The  intra-cardiac  ganglia  proper  are  never  macroscopic 
in  size.  They  are  made  up  of  scattered  unipolar  cells,  but  a 
few  may  be  bipolar.  The  connection  between  each  ganglion 
and  the  other  ganglia  is  very  intricate;  so  is  the  connection 
with  the  external  cardiac  nerves. 

The  most  powerful  of  the  intra-cardiac  ganglia  proper 
lies  in  the  auricular  saeptum.  The  paralysis  of  this  ganglion 
by  opium  will  cause  a  reversion  of  the  cardiac  contraction; 
and  the  motion  will  be  from  the  ventricles  to  the  auricles, 
instead  of  the  normal  contraction  from  the  auricles  to  the 
ventricles.  The  other  important  ganglia  are  Remak's  in  the 
wall  of  the  sinus  venosus,  at  the  point  of  union  with  the 
auricles;  Bidder's  near  the  junction  of  auricles  and  ventri- 
cles, and  the  one  in  the  auricular  sseptum.  There  are  no 
ganglia  in  the  ventricular  sn[?ptum  or  apex. 

Mechanics  of  the  Heart-Beat. — Although  much  work  has 
been  done  to  clear  up  the  mystery  surrounding  the  cardiac 
movements  Ziemssen  says,  "  The  heart  moves  upward  and 
to  the  right  during  contraction;"  while  Senac  claims  that  it  is 


ANATOMY    OF   THE    HEART  21 

depressed  forward  and  downward.  Perhaps  it  would  be  well  at 
this  time  to  recall  the  fact  that  there  is  no  anatomical  con- 
nection of  the  muscular  fibres  of  the  ventricles  with  those 
of  the  auricles,  therefore  influences  which  affect  the  one 
need  have  no  effect  on  the  other. 

The  cardiac  movements,  in  fact,  are  found  to  be  in  ac- 
cord with  the  theory.  The  two  auricles  contract  simultane- 
ously; before  this  action  ceases  and  about  one-tenth  of  a 
second  after  it  begins,  the  two  ventricles  contract  in  unison. 
The  ventricular  contraction  never  varies,  no  matter  how 
rapid  or  how  slow  the  heart-beat  as  a  whole  may  be.  A 
fourteenth  of  a  second  is  consumed  for  the  contraction  of 
the  ventricles.     (Kirke,  "  Text  Book  of  Physiology.") 

There  are  exceptions  to  the  generalizations  concerning 
the  heart.  A  case  was  reported  by  von  Ziemssen  and  Ter 
Gregorianz  of  a  woman  who  was  badly  injured  in  an  acci- 
dent. They  made  several  observations  on  the  heart-beat, 
and  found  that  the  auricles  kept  contracting  after  the  ven- 
tricular systole  had  commenced. 

The  impulse-beat  may  be  best  detected  in  the  left  fifth 
intercostal  space.  The  rhythm  of  the  heart-beat  and  the 
extraordinary  vitality  of  the  heart  are  full  of  interest  and 
of  great  practical  importance.  There  is  nothing  unusual 
about  the  contraction  of  the  cardiac  muscles,  it  is  simply 
analogous  to  that  of  the  unstriped  muscles.  The  movement 
of  the  heart,  as  a  whole,  during  the  heart-beat,  has  been 
happily  described  as  a  peristaltic  contraction.  This  power 
of  contraction  of  the  heart-beat  seems  to  be  a  force  or  power 
that  is  inherent  in  the  substance  of  the  heart.  Even  before 
the  embryonic  heart  is  differentiated  from  other  structures, 
that  is,  when  the  heart  consists  of  only  ordinary  cells,  before 
it  has  any  nervous  mechanism,  even  before  the  formation 
of  a  nervous  system  in  the  body  at  large,  there  are  cardiac 
contractions. 

The  inherent  force  or  power  which  seems  to  impel  the 


22  THE  SURGERY  OF  THE  HEART 

cardiac  substance  to  contract  is  well  illustrated  in  the  com- 
mon frog.  A  frog's  heart,  and  that  of  a  tortoise,  have  been 
known  to  beat  several  hours,  and  in  some  cases  even  days 
after  removal. 

When  the  beats  become  infrequent,  which  they  will 
sooner  or  later,  an  additional  one  can  be  induced  by  stimu- 
lating the  heart  with  a  blunt  needle.  The  latent  period  (time 
interval  between  application  of  stimulus  and  resultant),  how- 
ever, is  much  increased. 

See  says:  "  Ligation  of  one  coronary  artery  in  a  dog, 
in  two  minutes  caused  the  regular  cardiac  contractions  to 
give  place  to  fibrillar  twitchings,  and  that  ventricle  is  first 
chiefly  affected  whose  coronary  artery  has  been  ligated." 
(See  Chapter  on  Results  of  Experiments.) 

The  auricles  can  be  made  to  pulsate  independently  of 
the  ventricles,  and  at  a  different  rate,  by  a  transverse  in- 
cision through  the  junction  of  the  auricles  with  the  ven- 
tricles. 

The  rhythm  of  the  cardiac  movements  in  a  heart  wholly 
excised  differs  from  that  of  an  unremoved  heart.  The 
rhythm  in  an  excised  heart  is  in  order,  auricles,  ventricles, 
sinus  venosiis  and  bnlhiis  arteriosus.  The  heart  has  been  re- 
moved in  some  experiments  at  the  junction  of  the  sinus 
venosus  and  auricles,  and  in  such  cases  it  was  found  that 
while  the  remaining  portion  of  the  heart  continued  to  beat 
as  usual,  the  excised  portion  remained  motionless  for  a  varia- 
ble period,  and  when  movement  was  resumed,  the  rhythm 
differed  from  the  unexcised  portion. 

If  only  a  ventricle  be  removed,  the  period  of  quiescence 
will  be  longer  than  in  the  above  experiment.  The  rhythm 
also  of  the  excised  portion  will  differ  from  that  of  the  unre- 
moved portion. 

Division  of  the  heart  lengthwise  will  not  cause  any  change 
in  the  rhythm  of  the  two  parts;  each  will  continue  its  activi- 
ties as  before  the  incision.     If  an  auricle  be  cut  into  several 


ANATOMY    OF   THE   HEART  2$ 

pieces,  each  piece  will  still  pulsate.  Mitchell  {American 
Journal  of  Medical  Sciences,  Volume  VII,  p.  58)  inflated 
the  heart  of  a  sturgeon  with  air,  and  it  continued  to  beat 
after  removal  from  the  body,  until  the  auricle  became  so 
dry  that  it  rustled  during  its  movements. 

The  irritability  (property  of  reaction  to  stimuli)  of  the 
heart  of  the  higher  mammalia  is  of  greater  duration  in  very 
young  animals.  This  experimental  fact  agrees  with  the  law 
that  the  very  young  of  the  higher  mammalia  resemble  the 
cold-blooded  vertebrates,  in  the  power  of  sustaining  life  for 
lengthened  periods  without  oxygen. 

There  are  two  modes  of  stopping  the  heart's  action,  i.e., 
by  diminishing  the  strength  of  the  systole,  or  by  increas- 
ing the  length  of  the  diastole.  It  has  been  found  that  the 
contractile  power  of  the  right  side  of  the  heart  continues 
long  after  the  left  side  has  ceased  to  react  to  stimuli. 

The  exact  mode  in  which  each  part  of  the  heart  comes 
into  a  state  of  rest,  or  death,  has  not  been  determined.  It 
has  been  found  that  the  ventricles  cease  first  to  contract; 
the  left  auricle  stops  entirely;  finally  the  right  auricle  stops 
as  a  whole;  but  a  most  distinct  peristaltic  movement  may 
follow  along  the  auricular  appendix,  which  finally  gives  place 
to  a  gentle  fibrillar  tremor,  and  the  heart  is  at  rest  forever. 

As  the  heart  beats  more  and  more  slowly,  there  is  a 
marked  interval  between  the  auricular  and  ventricular  con- 
tractions. ("  Reference  Handbook  of  the  Medical  Sciences," 
Articles,  Circulation  of  the  Blood;  Thorax.) 

The  heart  will  beat  rhythmically  aside  from  the  body 
even  if  entirely  deprived  of  blood.  Reaction  to  stimulation 
of  the  intracardiac  ganglia  will  be  manifested  by  the  livelier 
action  of  the  heart,  but  the  influence  is  lost  sooner  and  the 
heart  will  come  to  rest  more  quickly  than  if  the  stimuli  be 
applied  elsewhere.  External  pressure  will  cause  a  variation 
in  the  rhythm  of  the  heart's  action,  but  the  heart-beat  will 
be  more  vigorous. 


24  THE  SURGERY  OF  THE  HEART 

The  effect  of  a  blow  near  the  umbilicus,  in  causing  the 
cessation  of  the  heart  action,  proves  the  intimate  connection 
existing  between  the  cardiac  nerve  mechanism  and  the  sym- 
pathetic nerve  system,  since  the  inference  is  very  plausible 
that  the  stoppage  is  produced  by  reflex  inhibition,  conveyed 
through  the  sympathetic  system. 

In  a  former  paragraph  reference  was  incidentally  made 
to  post-mortem  changes  in  the  heart.  Another  has  been 
remarked  regarding  the  ventricles;  it  is  said  that  in  a  well- 
marked  state  of  rigor  mortis  the  ventricular  cavity  will  be 
found  obliterated,  on  making  a  transverse  section. 

The  connection  between  the  action  of  the  heart  and  the 
function  of  respiration  is  of  great  practical  importance  in 
operative  surgery.  In  all  studies  of  the  mechanics  of  the 
heart  action  it  must  be  kept  in  mind  that  the  respiration  is 
the  most  important  of  all  the  dynamic  agents  which  affect 
this  action.  The  existence  of  extracardiac  centres  of  nerve 
force  which  exert  a  remarkable  influence  on  the  heart  beat, 
has  been  discovered.  These  extracardiac  centres  are  in 
juxtaposition  to  the  respiratory  centre;  hence  it  may  be 
justly  inferred  that  they  too  are  influenced  by  the  effects 
produced  by  variation  in  the  volume  of  oxygen  contained 
in  the  blood  supply. 

Obsen^ation  has  show^n  an  alteration  in  size  of  the  heart 
W'ith  each  pulsation;  this  causes  a  rhythmical  compression  of 
the  adjoining  lung  tissue.  The  process  by  which  part  at 
least  of  this  effect  is  produced,  has  been  explained  as  fol- 
lows: The  branches  of  the  pulmonary  artery  receive  acces- 
sion of  blood  at  each  right  ventricular  contraction ;  this 
causes  them  to  expand  rhythmically  in  accord  wath  the  heart- 
beat. 

The  periodical  expansion  of  the  arteries  produces  a  corre- 
sponding compression  of  the  bronchi.  There  is  nothing 
extraordinary  in  this,  since  it  has  been  remarked  by  com- 
parative anatomists  that  this  "  cardio-pneumatic  movement  " 


ANATOMY    OF   THE    HEART  25 

is  a  factor  in  changing  the  air  in  the  kings  of  hibernating  ani- 
mals. 

CHnical  experience  in  certain  diseases  where  there  is  great 
dyspnoea,  has  shown  that  the  dyspnoea,  if  prolonged,  makes 
the  left  ventricle  beat  feebly  sooner  than  the  right,  so  that 
the  left  side  of  the  heart  becomes  congested.  This  dams 
back  the  blood  into  the  pulmonary  veins.  This  may  be  a 
probable  cause  of  the  pulmonary  oedema  observed  in  the 
death  agony. 

The  influence  of  the  respiratory  function  is  apparent  not 
only  in  reference  to  the  cardiac  movements,  but  also  in 
reference  to  the  arterial  circulation.  The  expansion  of  the 
chest,  in  respiration,  relieves  the  extracardiac  pressure;  and 
the  contraction  of  the  chest  in  expiration  increases  the  press- 
ure upon  the  heart,  thus  producing  a  higher  arterial  tension. 
There  is  a  double  aspiration  carried  on  by  the  chest  and  by 
the  heart  itself.  Dogiel  says  that  "  artificial  respiration  slows 
the  blood  current  and  may  interrupt  it,  until  dyspnoeic  stimu- 
lation of  the  respiratory  centres  results."  Zuntz  claims  that 
"  opening  the  chest  wall  annuls  its  aspiration."  Beneke  found 
that  the  pulmonary  pressure  is  relatively  higher  in  a  child 
than  in  an  adult.  Lichtheim  says  that  the  plugging  of  one 
branch  of  the  pulmonary  artery  will  not  necessarily  alter 
the  aortic  pressure.  "  No  known  method  will  cause  a 
permanent  general  alteration,  of  any  extent,  in  the  blood 
pressure  of  the  whole  body."  (Cohnheim.) 

The  work  done  by  the  heart  is  enormous.  The  pressure 
within  the  cardiac  cavities  is  also  considerable;  there  is  both 
a  positive  and  a  negative  pressure.  The  negative  pressure 
of  the  right  ventricle  equals  two-thirds  of  an  inch  of  mer- 
cury; that  of  the  left  ventricle  equals  from  two  inches  to  two 
and  four-fifths  of  an  inch  of  mercury.  Part  of  this  negative 
pressure  of  the  left  ventricle  is  due  to  active  dilatation.  This 
has  been  found  to  equal  four-fifths  of  an  inch  of  mercury. 
Positive  pressure  in  the  right  auricle  equals  four-fifths  of  an 


26  THE  SURGERY  OF  THE  HEART 

inch  of  mercury.  At  each  diastole  the  pressure  in  both  auri- 
cles sinks  below  the  atmospheric  pressure  (fifteen  pounds 
to  the  square  inch,  thirty-nine  inches  of  mercury). 

Opening  the  thorax  in  operations  is  said  to  cause  a  fall 
in  blood  pressure.  Part  of  this  loss  of  pressure  is  due  to  the 
active  muscular  action  (dilatation  of  the  auricle  itself  inde- 
pendently of  respiration). 

The  negative  pressure  in  the  right  auricle  is  equal  to 
one-third  of  an  inch  of  mercury.  Work  done  by  the  right 
ventricle  is  only  one-third  of  that  done  by  the  left  ventricle. 
The  work  done  by  the  right  ventricle  is  equal  to  one  and 
one-eighth  foot  pounds.  The  work  done  by  the  left  ventri- 
cle at  each  systole  equals  three  and  three-eighths  foot  pounds. 
The  total  work  done  by  the  heart,  or  rather  by  the  two  ventri- 
cles, equals  four  and  one-half  foot  pounds. 

It  has  been  estimated  by  Haughton  that  the  mechani- 
cal energy  expended  by  the  heart  in  twenty-four  hours,  equals 
one  hundred  and  twenty-four  foot  tons.  Taking  seventy 
years  as  the  limit  of  a  man's  life,  the  work  done  by  a  normal 
heart  in  a  lifetime  of  this  length  will  equal  three  million 
one  hundred  and  twenty-four  thousand  and  eight  hundred 
foot  tons,  a  force  too  stupendous  to  be  grasped.  A  force 
of  this  magnitude  would  move  a  train  of  fifty-two  of  the 
largest  freight  cars  loaded  to  their  fullest  capacity  (twenty 
tons),  over  one-half  of  a  mile. 

In  the  several  veins  the  blood-pressure  varies  greatly, 
but  it  always  diminishes  toward  the  heart.  Change  of  position 
will  have  a  greater  effect  upon  the  venous  pressure  than  on 
the  arterial.  The  pressure  in  all  the  large  veins  at  the  heart 
has  been  found  to  be  always  negative.  (Ludwig,  Volkmann, 
Weyrich.)  W.  G.  Thompson  says  that  he  experimentally 
proved  the  statement. 

The  force  of  each  systole — the  work  of  the  heart — is 
one-tenth  greater  than  the  arterial  resistance.  The  blood 
was  driven  around  the  entire  circulation  by  an  equal  force 


ANATOMY   OF   THE   HEART  2/ 

produced  by  the  pressure  of  mercury.  (In  all  references  to 
mercurial  pressure  it  must  be  remembered  that  it  is  in  addi- 
tion to  the  atmospheric  pressure  of  fifteen  pounds  to  the 
square  inch,  or  thirty-nine  inches  o£  mercury.) 

An  amount  of  blood  equal  to  one-half  or  two-thirds  the 
whole  volume  normally  found  in  any  of  the  higher  verte- 
brates, may  be  injected  or  transfused,  without  danger  to 
the  animal  injected.  Death  follows  the  injection  of  a  volume 
of  blood  equal  to  one  and  one-half  times  the  normal  volume. 
But,  however  large  the  volume  of  blood  injected  may  be, 
short  of  death,  the  increase  is  temporary  only;  the  blood 
soon  shrinks  to  the  volume  normal  to  the  animal.  The  nor- 
mal volume  of  blood  cannot  be  increased  by  the  ingestion 
of  any  amount  of  food.  Increase  of  the  watery  element  of 
the  blood  produces  only  a  temporary  increase  in  the  total 
volume  of  the  blood.  Loss  from  haemorrhage  does  not  cause 
a  permanent  diminution,  but  the  loss  of  the  watery  element 
in  certain  diseases  will  cause  a  diminution  in  the  volume  of 
the  blood.  In  such  cases  the  blood  becomes  dark,  almost 
black,  and  of  the  consistency  of  tar. 

The  color  of  the  blood  varies  considerably,  but  as  a  rule 
the  arterial  blood  is  brighter  than  the  venous;  pure  arterial 
blood  has  a  vivid  red  color.  Any  impurity,  any  difference 
in  oxygenation,  and  even  the  slightest  admixture  of  impure 
blood  will  cause  a  decided  change  in  color.  Truly  arterial 
blood  is  nearly  saturated  with  oxygen,  and  the  plasma  con- 
tains only  a  small  amount  of  carbon  dioxide. 

The  process  of  coagulation  has  an  important  practical 
bearing  in  operative  surgery.  Coagulation  of  the  blood  is 
caused  by  the  formation  of  fibrin.  Fibrin  does  not  exist  pre- 
formed in  the  blood,  nor  is  it  held  in  solution  in  the  plasma, 
as  was  once  thought.  It  is  formed  by  the  action  of  fibrino- 
gen and  fibrinoplastin  in  the  presence  of  a  certain  ferment. 
The  plasma  holds  the  fibrinogen  in  solution,  and  the  white 
corpuscles  contain  the  fibrinoplastin,  or  paraglobulin,  and 


28  THE  SURGERY  OF  THE  HEART 

also  the  ferment.  The  fibrinoplastin  and  ferment  are  set  free 
by  the  death  .of  the  white  corpuscles.  The  fibrinoplastin, 
thus  freed,  is  acted  upon  immediately  by  the  fibrinogen,  under 
conditions  that  permit  chemical  action.  The  ferment  does 
not  seem  to  take  any  active  part  in  this  process,  but  per- 
forms that  inexplicable  function  observed  in  many  chemical 
reactions. 

Many  chemical  combinations  can  be  produced  only  when 
the  constituent  elements  act  upon  one  another,  in  the  pres- 
ence of  some  substance,  which  forms  no  part  of  the  resultant 
substance,  and  does  no  discoverable  work  in  the  chemical 
reaction. 

When,  from  any  cause,  there  is  loss  of  lining  endothelium, 
white  blood-corpuscles  adhere  to  the  denuded  spot,  and  by 
their  death  bring  about  the  formation  of  fibrin. 

If  infection  occurs,  the  presence  of  micro-organisms  or 
the  chemical  compounds,  however  formed,  resulting  from 
their  presence,  will  cause  a  septic  or  putrid  softening  under 
the  above  circumstances.  These  processes  will  account  for 
the  formation  and  structure  of  the  exudative  adhesions,  ob- 
served in  the  autopsies  of  the  dogs  used  for  this  series  of 
experiments.     (See  Chapter  on  Results  of  Experiments.) 


BIBLIOGRAPHY 

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132;   I    pi. 

SCHNECHBAUR,  Augjpoli,   1780. 

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in  Coll.;  Acad.  d.  Mein.,  etc.,  Paris,  1786,  XI,  349,  422. 
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Ramsey,  A,,  Edinburgh,  1813. 


Plate  V. 


X  160. 

Transverse    Section    of    Cardiac    Muscular    Fibres 

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(Dr.  A.  V.  Meigs.) 


X  1(>(). 
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Showing  Main  Blood  Vessel  and  Its  Ramify- 
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(Anatomy  of  the  Heart.) 


ANATOMY   OF   THE    HEART  29 

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567- 
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tomie,   Physiologie   und    Pathologic    des   Herzen,   des    herz 

bentels  und  des  Brustfelles,  Prague,  1858. 
Mitchell,  S.  W.,  American  Journal  of  Science,  Philadelphia, 

1859,  n.  s.,  XXXVII,  343-348. 
Gautier  du  Depix,  Paris,  i860. 

Macnamara,  J.,  Medical  Times  and  Gazette,  London,  1861,  L.  345. 
Weismann,  Arch.  f.  Anat.  Physiol,  u.  wissen  Medical,  Leipzig, 

1861,  41-63. 
JouRDAN,  S.,  Soc.  de  Biol.,  1861,  Paris,  1862;  3,  5,  11,  106-109. 
Phillippo,  Edinburgh  Medical  Journal,  1862,  VII,  684. 
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500;  5  Pl- 
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Brandt,  A.,  Melanges  Biol.  Acad.  imp.  d.  Sc.  de  St.  Petersburg, 

1866,   VI,    101-114;    Also  Transl.  (Abstr.).    Med.    Vestnik, 

St.  Petersburg,  1866,  VI,  74,  87. 
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1866;  II,  365-375- 
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1868,  302-325. 
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30  THE  SURGERY  OF  THE  HEART 

ToNGE,  M.,  Philadelphia  Tr.,  London,  1869,  CLIX,  387-411 ;  2  pi. 
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1873,  XXVII,  327-333- 

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III,  97-100. 

DoGiEL,  J.,  Arch,  de  Physiol,  norm,  et  path.,  Paris,  1877,  2  s., 

IV,  400-408;  I  pi. 

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249-266. 
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39-42;  Arch.  }.  Mikr.  Anat.,  Bonn,  1877,  XIV,  459-470;  2  pi. 
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(On  the  structure  of  the  snail's  heart.) 
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perimental, Virginia  Medical  Monthly,  March  10,  1899. 


CHAPTER    II 

EXPERIMENTAL    RESEARCH 

In  reviewing  the  literature  pertaining  to  the  experimental 
research  referring  to  the  surgery  of  the  heart,  little  is  found 
as  compared  with  that  bearing  on  the  physiology  of  the 
heart.  Physiologists  have  offered  but  little  if  any  encourage- 
ment in  dealing  with  cardiac  injuries.  What  has  been  done 
experimentally  and  with  injuries  to  the  human  heart  has 
been  independent  of  the  teachings  of  the  physiologist.  As 
soon  as  the  investigator  had  concluded  his  work  upon  the 
lower  animals  (and  every  such  investigator  appears  to  have 
been  a  surgeon)  he  reasoned  from  animal  to  man,  and  justly 
so,  as  proven  by  subsequent  events  in  the  domain  of  surgery 
upon  the  human  heart. 

Historical. — Hering  was  the  earliest  to  ascertain  the  rapid- 
ity of  the  circulation.  He  introduced  prussiate  of  potash 
(cyanide  of  potassium)  into  one  part  of  the  system  and  drew 
blood  from  another.  Legallois,  in  1813,  experimented  on 
the  principle  of  life,  and  particularly  on  the  principle  of  the 
motion  of  the  heart  and  on  the  seat  of  this  principle.  Witt- 
bank,  in  1824,  made  a  series  of  experiments  to  determine 
the  cause  of  the  action  of  the  heart.  Hope,  in  1830,  entered 
into  an  experimental  and  clinical  study  of  the  physiology 
of  the  heart's  action.  Brown-Sequard,  in  1853,  Chauveau, 
in  1856,  Halvord,  in  1858,  Upham,  in  1859,  Berner  and  Flint, 
in  1 861,  and  Bernard,  in  1879,  each  made  an  extensive  exper- 
imental study  with  reference  to  the  heart's  action. 

Roberts,  in  1881,  determined  from  experimental  investi- 
gation that  puncture  of  the  heart  with  suture  of  it  would 

31 


32  THE  SURGERY  OF  THE  HEART 

become  a  therapeutic  measure.  Block  sutured  the  cut  ven- 
tricular wall  of  a  rabbit  in  1882.  It  was  not  until  1884  that 
Howell  and  Donaldson  made  their  experiments  upon  the 
dog.  Sewall,  in  1884,  conducted  experiments  with  reference 
to  the  physiology  of  the  intermittent  heart.  Kronecker  and 
Schmey,  in  1884,  showed  by  experiments  upon  rabbits  that 
needle  puncture  at  a  certain  point  in  the  saeptum  between 
the  ventricles  produced  death  by  injuring  the  large  nerve 
ganglia,  which  are  derived  only  from  the  sympathetic.  The 
influence  is,  therefore,  sensory  and  not  motor.  Pennock 
and  Moore  also  experimented  to  determine  the  action  of  the 
heart.  Senn,  in  1885,  made  an  experimental  and  clinical 
study  of  air  embolism  (thirty-nine  experiments  on  dogs). 
He  showed  that  it  was  possible  to  remove  air  from  the  cham- 
bers of  the  heart  by  means  of  an  aspirating  needle  without 
fatal  results.  Phillipson  made  experiments  to  determine  the 
advisability  of  applying  sutures  in  wounds  of  the  heart.  This 
was  in  1886,  and  he  was  followed  by  Del  Vecchio  in  1895, 
who  showed  by  experiments  upon  dogs  the  possibility  of 
suturing  heart-wounds  in  man. 

Cohnheim  showed  that  pressure  in  the  pericardium  from 
fluid  was  upon  the  auricles,  that  the  ventricles  would  con- 
tinue to  contract,  and  that  sufHcient  pressure  would  stop 
contraction  of  both  auricles  and  ventricles.  Romberg 
showed,  before  nerves  and  ganglia  were  found  in  the  cardiac 
muscle,  that  the  foetal  heart  contracted  rhythmically. 

Porter  says  that  the  cause  of  rhythmic  contraction  of 
the  ventricle  lies  in  the  ventricle  itself.  (Journal  of  Exp.  Med., 
I,  1895,  p.  319.) 

Ten  out  of  sixty  animals,  though  their  hearts  had  ceased 
to  beat,  were  restored  to  life  by  the  puncture,  and  com- 
pletely recovered.  One  of  them,  indeed,  after  two  experi- 
ments, recovered  twice.  All  except  one  puncture  in  the  ten 
cases  were  made  in  the  right  ventricle.  These  experiments 
were  made  by  Watson  and  are  referred  to  by  Paget.  1897. 


EXPERIMENTAL    RESEARCH  33 

They  demonstrate  in  a  beautiful  manner  that  such  means 
of  cardiac  stimulation  may,  at  times,  be  beneficial,  now  and 
then  completely  restoring  life.  Crile,  in  1897,  showed  that 
gunshot  wounds  of  the  heart,  not  penetrating  the  chambers, 
caused  but  temporary  arrhythmia  for  several  beats.  Dana, 
in  1897,  stated  that  he  had  often  punctured  the  heart  in 
animals,  and  by  so  doing  had  stimulated  and  never  checked 
it ;  but  he  got  no  results  in  two  cases  in  practice. 

Elsberg,  in  1899,  made  a  most  elaborate  experimental 
investigation  of  the  treatment  of  wounds  of  the  heart  by 
means  of  suture  of  the  heart-muscle.  He  has  shown  con- 
clusively that  suture  of  open  wounds  of  the  heart  is  a  most 
rational  procedure.  How^ever,  it  had  been  successfully  ac- 
complished in  man  in  1896.  Elsberg  thinks  there  is  much 
doubt  as  to  the  existence  of  new  muscle  fibres  in  hypertrophic 
hearts,  especially  in  the  longitudinal  diameter  of  old  fibres. 
But  connective  tissue  may  degenerate;  if  it  does,  the  normal 
tissue  surrounding  it  does  not  seem  to  do  so.  He  further 
says  that  muscle  fibres  are  destroyed  by  trauma  and  replaced 
by  connective  tissue,  but  the  change  does  not  interfere  with 
cardiac  function.  In  one  of  his  experiments  he  amputated 
the  apex  of  the  heart,  necessitating  the  opening  of  one  of 
the  ventricles,  and  sutured  the  cut  surfaces  together  with- 
out loss  of  the  rabbit's  life. 

Brunton  {Journal  of  the  Amer.  Med.  Ass'n.,  March,  1902. 
p.  589)  has  conducted  a  series  of  experiments  upon  cats  and 
the  dead  human  body  to  show  the  possibilities  of  surgical 
operations  for  mitral  stenosis.  He  states  that  not  only 
should  the  pericardium  be  opened  for  the  operation,  but 
that  it  should  be  left  open  to  give  exit  to  any  oozing  or 
haemorrhage,  as  the  heart  has  little  power  to  resist  rapidly 
occurring  intrapericardial  pressure.  He  also  says  that 
haemorrhage  is  greater  from  a  needle  puncture  in  the  auricle 
than  in  the  ventricle,  even  though  the  same  needle  be  used. 

N.  I.  Botcharoff  made  pharmacologic  experiments  on  the 


34  THE  SURGERY  OF  THE  HEART 

isolated  heart  of  warm-blooded  animals.  Villar  conducted 
experiments  upon  suturing  wounds  of  the  hearts  of  animals. 
H.  M.  Sherman  reported  his  observations  on  experimental 
heart  surgery.  G.  V.  N.  Dearborn,  in  1903,  made  a  physiolog- 
ical study  on  a  crustacean  heart. 

"  Conclusions — The  operations  which  have  been  recorded 
mark  only  the  beginning ;  the  heart  is  now  destined  to  be  sub- 
mitted to  many  manipulations,  provided  they  may  be  done 
without  stopping  its  action  at  once.  It  is  a  very  unsafe  thing 
to  prophesy,  but  that  more  will  be  attempted  can  easily  be  in- 
ferred, for  interference  with  the  mitral  orifice  has  already  been 
si-^ggested  and  the  immediate  neighborhood  of  the  heart  has 
been  invaded  and  a  sacculated  aneurysm  of  the  aorta  has  been 
tied  off,  the  success  of  this  well-executed  maneuvre  being  pre- 
vented only  by  the  failure  of  the  atheromatous  vessel  walls  to 
heal.  Possibly  the  next  step  may  be  delayed  as  long  as  the 
application  to  the  heart  of  common  surgical  methods  was  de- 
layed after  Desault  had  taught  us  to  open  the  pericardium. 
Perhaps  it  may  come  soon.  It  is  not  impossible  that  a  new 
surgical  technic  may  have  to  be  created,  but  it  is  most  proba- 
ble that  the  next  step  will  be  based  on  the  new  application  of 
the  very  old  matters  of  suture  and  drainage." 

(H.  M.  Sherman,  Suture  of  Heart  Wounds,  Journal 
American  Medical  Association,  1902,  xxxviii,  1 560-1 568.) 

Surgical  Shock — "  Surgical  shock  is  in  all  probability  allied 
to  the  physiological  phenomenon  of  inhibition,  but  differs 
from  the  physiological  condition  in  that  it  involves  to  a 
greater  or  less  degree  the  entire  nervous  system.  An  inhibi- 
tion of  unimportant  areas  is  not  likely  to  be  followed  by 
serious  results,  but  an  inhibition  of  vital  centres  will  prove 
fatal  if  severe  or  long  continued. 

"  Of  the  important  nerve  centres  in  the  nervous  system, 
the  vasomotor  centres  take  first  rank.  Hence,  in  surgical 
shock  it  is  the  vasomotor  inhibition  which  calls  most  urgently 
for  treatment. 


EXPERIMENTAL   RESEARCH  35 

"  It  is  necessary  to  keep  in  mind  the  fact  that  vasomotor 
collapse  involves  principally  the  arterioles;  the  heart,  prob- 
ably through  its  connection  with  the  nervous  system,  is  also 
implicated,  but  much  less  seriously.  The  heart  is  an  organ 
that  will  stand  a  great  many  insults  and  much  hard  treat- 
ment, as  those  who  work  on  lower  animals  are  aware;  but 
the  vasomotor  system  is  exceedingly  sensitive  and  imme- 
diately resents  any  abuse  by  causing  a  relaxation  of  the 
arterioles  throughout  the  body.  In  consequence  of  this,  the 
blood  pressure  falls,  the  pulse  weakens  or  disappears,  and 
unless  some  heroic  method  of  resuscitation  is  adopted  the 
patient  dies  of  collapse.  The  heart  continues  beating  for 
some  time  after  the  arterioles  relax,  but  its  contractions 
are  feeble  and  often  irregular.  Later  on,  the  heart  stops  its 
contractions;  but  here  again  the  cause  lies  not  so  much  in 
the  heart  as  in  the  falling  blood-pressure  produced  by  the 
relaxed  arterioles.  When  the  blood  pressure  sinks,  blood 
can  no  longer  be  forced  into  the  coronary  arteries,  and  the 
heart  stops  in  consequence  of  a  lack  of  oxygen.  It  is  for 
this  reason  that  the  mammalian  heart  does  not  beat  rhythmi- 
cally when  excised  from  the  body;  its  removal  stops  the 
coronary  circulation,  and  the  organ  ceases  its  beating.  When 
defibrinated  blood  Is  transfused  through  the  coronary  ves- 
sels, the  mammahan  heart  can  be  made  to  resume  its  con- 
tractions outside  of  the  body.  It  is  the  vasomotor  system, 
then,  rather  than  the  heart,  which  requires  treatment  in  con- 
ditions of  sudden  collapse. 

"  There  is  another  factor  in  vasomotor  collapse  which 
must  not  be  overlooked.  When,  in  consequence  of  overstimu- 
lation or  of  some  poison  in  the  blood,  the  vasomotor  centres 
give  way  and  the  arterioles  relax,  the  circulation  in  the  cen- 
tral nervous  system,  where  vasomotor  centres  reside,  is  inter- 
fered with.  As  a  result  less  blood  circulates  through  the 
brain  and  the  spinal  cord,  and  therefore  less  blood  is  carried 
to  the  failing  vasomotor  centres.     A  vicious  circle  is  estab- 


36  THE  SURGERY  OF  THE  HEART 

lished  in  this  way,  and  eventually  the  blood-pressure  sinks  to 
nil,  unless  we  can  l^reak  the  vicious  circle  and  give  the 
vasomotor  centres  a  chance  to  recover  under  an  increased 
blood  supply.  Strychnine  and  whiskey  act  principally  by 
direct  stimulation  of  these  centres,  and  their  administration 
is  followed  by  the  desired  results,  provided  the  nerve  cells 
are  not  beyond  the  capability  of  reaction.  When,  however, 
the  nerve  cells  are  powerfully  shocked,  a  direct  stimulation 
depresses  rather  than  stimulates  them. 

"  The  injection  of  normal  saline  solution  is  then  more  likely 
to  be  followed  by  favorable  results,  because  the  liquid,  by 
mechanically  filling  the  blood-vessels,  partially  compensates 
for  the  loss  of  tone  produced  by  the  relaxed  arterioles.  If 
the  vasomotor  centres  are  not  too  seriously  involved,  they 
react  under  the  increased  blood  supply  brought  about  by 
the  injection,  and  recovery  results.  But.  as  all  surgeons 
know,  even  the  normal  saline  solution  occasionally  fails  to 
do  its  work  properly;  in  fact,  we  found  in  our  experiments 
that  even  copious  injections  were  accompanied  by  a  distinct 
fall  of  pressure  in  animals  suffering  with  severe  vasomotor 
shock. 

"  Adrenalin,  according  to  Takamine.  is  the  active  princi- 
ple of  the  medulla  of  the  suprarenal  bodies.  When  injected 
into  the  circulation,  it  causes  an  enormous  rise  in  blood  press- 
ure, due  not  so  much  to  the  stimulation  of  the  vasomotor 
centres  as  to  the  direct  stimulation  of  the  heart  and  arterioles. 
It  produces  its  effects  almost  as  well  on  the  heart  and  blood- 
vessels isolated  from  the  central  nervous  system  as  when  they 
are  in  physiological  connection  with  their  nerve  centres. 
When  it  is  injected  directly  into  the  blood  stream  of  an  ani- 
mal, the  rise  is  prompt,  powerful,  but  not  prolonged.  The 
remedy  appears  to  be  very  rapidly  destroyed  or  neutralized 
in  the  blood,  or  more  probably  in  the  tissues.  In  adrenalin, 
then,  we  have  an  agent  which  can  rapidly  overcome  vaso- 
motor shock  by  acting,  not  on  the  centres  themselves,  but 


Plate  VI. 


X  IGO. 

Transverse  Section  of  Cardiac  Muscular  Fibres  and 
Capillaries.    (Dr.  A.  V.  JNIeigs.) 


X  00. 

Transverse   Section   of    Cardiac    Muscular    Fibres. 
(Dr.  A.  A'.  ^leigs.) 


(Anatomy  of  the  Heart.) 


EXPERIMENTAL   RESEy\KC,II  37 

directly  on  the  heart  and  arterioles,  but  which  unfortunately 
is  very  evanescent  in  its  action  when  injected  into  the  blood. 
In  order  to  make  it  a  useful  remedy  for  the  treatment  of 
the  condition  under  consideration,  its  action  must  be  made 
more  prolonged  and  preferably  less  powerful. 

"  In  a  research  undertaken  by  Dr.  May  Miles  and  myself, 
we  found  that  when  the  adrenalin  was  diluted  to  one  in  ten 
thousand  and  about  one  cubic  centimetre  was  injected  hypo- 
dermically,  the  vasomotor  collapse  consequent  on  ether  poi- 
soning could  be  completely  overcome.  The  blood  pressure 
in  the  rabbits  experimented  on  rose  rapidly  and  remained 
elevated  for  two  hours  or  longer.  The  site  of  the  injection 
must  be  vigorously  massaged  in  order  that  absorption  may 
be  promoted.  We  inferred  from  these  experiments  that 
adrenalin  in  the  strength  and  by  the  method  indicated  would 
be  a  valuable  remedy  for  surgical  shock.  The  increased  blood 
pressure,  by  improving  the  circulation  through  the  central 
nervous  system  overcomes  the  inhibition  and  permits  a 
restitution  to  a  normal  physiological  tone." — William  Muhl- 
berg,  M.D. 

BIBLIOGRAPHY 

Hering,  Tiedemann's  Zeitschrift,  Vol.  Ill,  p.  85. 
Valentin,  Lehrhuch  der  Physiologie,  Verhandlung  I,  p.  427. 
Legallois,  C.  J.  J.,  Transl.  by  N.  C.   &  J.  G.  Nancrede,  Phila- 
delphia, 1813. 
WiTTBANK,  J.,  Phila.  Journal  Med.  and  Chir.  Soc,  1824,  IX,  361- 

376. 
Hope,  J.,  London  Med.  Gaz.,  1830,  VI,  782-935. 
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Blake,  Edinb.  Med.  and  Surg.  Journal,  Oct.,  1841. 
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Weber,  Arch,  d'  Anal.  Gencr,  et  de  Physiol.,  Jan.,  1846. 


38  THE  SURGERY  OF  THE  HEART 

Brown-Sequard,  Experimental  researches  applied  to  Physiology 

and  Pathology,  New  York,  1853. 
Chauveau  ex  Faivre,  Gaz.  Med.  de  Paris,  1856,  3  s.,  XI,  365,  406, 

457- 

Halford,  G.  B.,  Med.  Times  and  Gaz.,  London,  1858,  XVI,  109, 
191,  391. 

Upham,  J.  B.,  M.  Groux,  Boston,  1859. 

Berxer,  H.,  Lehre  von  der  Herzbewegung,  Erlangen,  1859. 

Flint,  A.,  Am.  Jour.  0}  the  Med.  Sc,  1861,  XLII,  341-381. 

Halford,  Lancet,  London,  1867, 1,  19. 

Bernard,  C.,  Physiologic  operatoire,  1879,  Paris. 

Roberts,  John  B.,  Tr.  of  the  College  of  Phys.  and  Surg.,  Phila- 
delphia, 1881-3;  Vol.  VI,  215-219. 

Howell  and  Donaldson,  Phil.  Trans,  of  the  Roy.  Soc,  Part  I, 
1884,  p.  139,  London. 

Sewell,  H.,  Phys.  and  Surg.,  Ann  Arbor,  1884,  VI,  145-150. 

Kronecker  and  Schmey  (Sitzungsberichte  d.  Berliner  Akad., 
1884,  p.  87. 

Senn,  Trans,  of  the  Amer.  Surg.  Ass'n.,  1885,  Vol.  Ill,  p.  187. 

Phillipon,  Russian  Medicine,  St.  Petersburg,  1886,  IV,  187. 

Romberg,  Deutsche  Med.  Wochenschrift,  1889,  p.  549. 

Krehl,  Deutsche  Med.  Wochenschrift,  1889,  p.  549. 

Kolster,  R.,  Experiment  Studium  iiber  de  und  regenerative  vor- 
gange  am  Herzmuskel  bei  Gefasssperre  (Myomalacia  cordis, 
Ziegler),  Res.  pp.  XLIII-XLV,  Festskr.  f.  path.  anat.  Inst. 
Helsingfors. 

ScHAEFER,  Verhandl.  d.  IX  Congress  f.  innere  Medicine,  1890. 

His,  W.,  and  Romberg,  Arch. }.  exp.  Path.  u.  Pharni.,  1892,  XXX, 

51- 
Delorme,  Chir.  dc  guerre,  1893. 
Del  Vecchio,  Riv.  Med.,  April  4,  1895. 
Porter,  Jour,  of  Exper.  Med.,  1895,  I,  319. 
Rosenthal,  Deutsche  Med.  Woch.,  1895,  No.  2. 
Engelman,  Archiv.  f.  d.  ces.  Phys.,  1896,  LXV,  119,  535. 
Delorme   et   Mignon,  Revue  de  chir.,  1895,  pp.  797-987,  and 

1896,  p.  56. 


EXPERIMENTAL   RESEARCH  39 

Salomoni,  Centralbl.  j.  Chir.,  1896,  No.  51. 
VoiNiTCH-SiANOjENSKY,   Arcliiv.   Tuss.  de  chir.,  St   Petersburg, 

1867,  II. 
Rehn,  Langenbeck's  Arch.,  1897,  LV,  315. 
Bode,  Beitrage  z.  klin.  Chir.,  1897,  XIX,  167. 
Elsberg,  C.  a.,  Journal  oj  Exper.  Med.,  Baltimore,  Vol.  LV, 

Nos.  5,  6,  Sept.,  Nov.,  1899. 
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Rose,  Deutsche  Zeitschr.  /.  Chir.,  XX,  329. 
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180. 
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pp.  1560-65. 
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Tri-State  Med.  Soc,  1903. 
Dearborn,  G.  V.  N.,  Med.  News,  March  20,  1903,  pp.  596-601. 


CHAPTER  III 
CARDIAMORPHIA 

etiology — Embryologists  claim  that  the  s^eptum  of  the 
auricle  is  completed  by  the  sceptum  growing  backward,  as 
it  were,  and  uniting  with  the  saeptum  intermedium.  How- 
ever, before  this  process  is  completed,  several  other  changes 
occur,  while  the  superior  saeptum  is  forming  the  saeptum  inter- 
medium is  also  in  a  state  of  formation,  and  between  these 
two  saepta  at  this  stage  of  development  there  is  an  opening 
which  was  formerly  thought  to  be  the  origin  of  the  fora- 
men ovale,  but  Bern  and  other  investigators  have  shown  that 
a  secondary  rupture  occurs  in  the  superior  sseptum. 

The  opening  thus  formed  by  the  secondary  saeptum  of 
the  superior  saeptum  becomes  the  foramen  ovale.  It  is  very 
probable  that  many  of  the  cases  of  patency  of  the  foramen 
ovale  which  have  been  reported  have  not  been  in  fact  what 
they  were  thought  to  be.  There  is  a  very  great  possibility 
that  the  condition  observed  was  due  to  an  arrest  in  the  nor- 
mal development  of  the  embryo's  heart. 

The  opening  that  is  found  between  the  superior  saeptum 
and  the  saeptum  intermedium  has  never  been  closed,  either 
because  the  union  of  the  two  saepta  has  been  hindered  or 
because  further  development  of  this  part  of  the  heart  has 
ceased  from  some  cause. 

In  other  cases  the  effect  may  have  been  produced  later. 
Some  cause  may  have  prevented  the  development  of  the  sec- 
ondary saeptum,  or  it  has  not  conformed  to  the  changes  which 
have  taken  place.     It  is  not  enough  of  a  secondary  saeptum 

to  make  (also)  a  valve  for  the  foramen  ovale. 

40 


CARDIAMORPHIA  4I 

The  heart  may  be  abnormally  small  (hypoplasia).  Vir- 
chow  says  that  such  a  condition  is  most  frequently  found  in 
chlorotic  persons — the  haemophiliacs.  Two  or  more  imper- 
fect hearts  may  be  found  in  the  same  chest.  Atrophy  of  the 
heart's  walls  may  occur  without  lessening  the  size  of  its 
chambers. 

Malformations  of  the  heart  are  of  many  varieties,  and 
they  all  vary  more  or  less  in  degree  and  must  necessarily 
be  considered  in  a  work  of  such  a  character  as  this,  the  object 
being  to  present  those  defective  hearts  that  will  best  illustrate 
the  object  intended,  namely  the  surgical  features.  Mal- 
formations and  anomalies  must  of  necessity  be  considered 
together,  while  displacements  and  malpositions  can  be 
similarly  classified. 

No  doubt  death  from  non-closure  of  the  foramen  ovale 
is  less  frequent  than  is  generally  supposed,  other  abnormities 
being  the  cause.  Autopsies  are  secured  in  but  a  small  per 
cent,  of  such  cases. 

Historical  (1675-1903). — Openings  between  the  ventricles 
may  be  congenital  or  acquired,  and  are  of  many  varieties, 
degrees,  and  locations,  as  shown  by  the  various  reporters, 
among  whom  Marshall,  in  1830,  mentions  a  very  interesting 
case,  as  does  Bertody,  in  1845,  a-^so,  when  he  reports  a  case 
of  communication  between  the  ventricles  of  the  heart,  the 
aorta  originating  from  both  ventricles.  In  the  case  of  Par- 
ker, in  1846,  the  aperture  was  in  the  saeptum  of  a  heart  having 
considerable  contraction  of  the  pulmonary  orifice,  with  the 
aorta  arising  entirely  from  the  right  ventricle.  Ouain  (1846) 
showed  a  congenital  perforation  at  the  base  of  the  saeptum 
ventriculorum.  A  similar  one  is  mentioned  by  Bennett 
(1846),  but  that  of  Peacock  (1848)  was  a  much  larger  fora- 
men ovale  than  is  usually  found  dependent  upon  contraction 
of  the  aortic  orifice.  In  the  case  of  Mayne  (1847)  the  open 
foramen  ovale  had  caused  remarkable  derangement  of  the 
circulation.     In  Jenner's  cases   (1848)  the  subjects  did  not 


42  THE  SURGERY  OF  THE  HEART 

have  any  disturbance  of  the  circulation,  but  in  that  of  Lloyd 
(1848),  there  was  considerable  dilatation  of  the  right  side  of 
the  heart.  None  of  these  manifestations  was  displayed  in 
the  case  of  Wienholt  (1848).  However,  there  was  great  cyano- 
sis in  a  case  reported  by  Lee  (1849),  in  which  the  opening 
between  the  ventricles  was  near  the  mouth  of  the  aorta,  with 
contraction  of  the  pulmonary  artery.  One  of  the  most  inter- 
esting of  the  pathological  conditions  of  this  type  of  anomalies 
is  reported  by  Hutchinson  (1853),  in  which  he  mentions  a 
malformation  of  the  heart  in  a  child  who  had  suffered 
from  cyanosis.  There  was  an  imperfect  ventricular  saeptum, 
with  a  rudimentary  right  ventricle  which  had  been  divided 
into  two  chambers  by  a  fleshy  saeptum  between  its  sinus  and 
its  infundibular  portion. 

Peacock  (1859)  reports  a  large  open  foramen  ovale  without 
cyanosis,  while  Callender's  case  revealed  a  perforation  of  the 
saeptum  ventriculorum  with  clots  in  some  of  the  pulmonary 
arteries  undergoing  various  changes.  Wagstaffe  (1868)  re- 
ports two  cases  of  free  communication  between  the  auricles 
by  deficiency  of  the  upper  part  of  the  saeptum  auriculorum  in 
persons  aged  fifty-two  and  six  years  respectively.  There  was 
no  cyanosis  in  either  case.  In  the  case  of  Holt  (1884)  there 
was  an  open  foramen  ovale  and  an  open  ductus  arteriosus 
with  stenosis  of  the  aorta  and  hypertrophy  of  both  ventricles. 
Haddon  (1890)  reports  a  case  in  which  there  was  a  patent 
foramen  ovale  in  an  adult,  and  Griffith  (1896)  mentions  a 
case  of  perforate  saeptum  ventriculorum  and  remarks  on  its 
diagnosis.  Solomon  (1898)  reports  a  case  of  patent  foramen 
ovale  and  an  extra  coronary  artery. 

Aorta  and  Pulmonary  Artery — Transposition  or  oblitera- 
tion of  the  pulmonary  artery  is  quite  common.  It  may  open 
into  any  one  or  all  of  the  cavities  of  the  heart,  as  may  the 
aorta  also.  Indeed,  the  pulmonary  artery  may  connect  with 
the  aorta  directly.  Reid  (1835)  reports  a  case  of  oblitera- 
tion of  the  vena  cava  superior  at  its  entrance  into  the  heart, 


CARDIAMOKl'IIIA  43 

while  West  mentions  a  case  of  malformation  of  the  heart 
and  great  vessels  attended  with  cyanosis.  In  the  case  of 
Bertody  (1835)  not  only  did  the  aorta  originate  from 
both  ventricles,  but  there  was  a  communication  betw^eeii 
them. 

In  the  diseased  heart  reported  by  Dalrymple  (1846)  the 
root  of  the  aorta  had  an  opening  common  to  the  ventricles. 
In  Parker's  case  (1846)  the  aorta  arose  entirely  from  the 
right  ventricle.  Cheever  (1846)  reports  a  case  illustrating 
the  earliest  stage  of  malformation,  usually  known  as  distri- 
bution of  the  descending  aorta  from  the  pulmonary  artery. 
Peacock  (1847)  reports  a  case  of  malformation  of  the  heart 
in  which  death  resulted  from  obstruction  in  the  trunk  of  the 
pulmonar}^  artery.  He  again  reports  (1848)  a  case  in  which 
there  was  contraction  of  the  pulmonary  orifice  which  par- 
tially originated  from  the  right  ventricle. 

In  the  case  of  Canton  (1848)  there  was  complete  oblitera- 
tion of  the  origin  of  the  aorta.  In  Ward's  (1850)  case  there 
was  transposition  of  the  aorta  and  pulmonary  artery.  Grieg 
(1852)  mentions  a  case  in  which  the  pulmonary  artery  was 
given  off  from  the  descending  aorta  and  left  subclavian 
artery.  In  the  case  of  Peacock  (1853)  there  was  great  con- 
traction of  the  pulmonary  orifice  with  deficiency  of  the  s?ep- 
tum  ventriculorum  and  open  foramen  ovale.  In  another 
(1855)  both  auricles  opened  into  the  left  ventricle  and  there 
was  transposition  of  the  pulmonary  artery  and  aorta.  In 
still  another  (1859)  he  reports  absence  of  the  ductus  arterio- 
sus with  a  small-sized  pulmonary  artery  and  the  aorta  aris- 
ing from  both  ventricles.  There  was  great  irregularity  in 
the  course  of  the  aorta.  In  the  case  of  Baly  (1856)  the 
pulmonary  artery  was  impervious  at  its  origin.  In  the  case 
of  Schilling  (1857)  there  was  an  abnormal  arrangement  of 
the  larger  vessels  to  the  heart. 

Abrahamson,  in  1857,  reports  a  case  in  which  there  was 
partial  obliteration  of  the  ascending  aorta.     Meigs,  in  i860, 


44  THE  SURGERY  OF  THE  HEART 

briefly  reports  a  case  in  which  there  was  transposition  of 
the  heart's  vessels. 

Nunneley  (1862)  writes  extensively  on  a  condition  which 
he  found,  in  which  the  aorta  freely  communicated  with  both 
ventricles,  and  these  with  each  other;  the  walls  were  small 
and  thin  and  the  pulmonary  artery  had  a  small  slit-like  open- 
ing into  the  ventricle.  There  was  an  open  foramen  ovale. 
Cockle  (1863)  reports  a  case  in  which  there  was  transposi- 
tion of  the  great  vessels  of  the  heart.  Peacock  (1864)  re- 
ports a  case  in  which  there  was  obliteration  of  the  orifice  of 
the  pulmonary  artery,  with  an  open  foramen  ovale  and  ductus 
arteriosus;  there  was  cyanosis.  In  another  case  which  Pea- 
cock mentions  (1869)  there  was  atresia  of  the  orifice  of  the 
pulmonary  artery,  and  the  aorta  communicated  with  both 
ventricles.  He  speaks  of  a  similar  case  the  same  year  and 
of  another  one  in  1870.  During  this  year  (1870)  he  reports 
a  case  of  great  contraction  of  the  pulmonic  orifice,  the 
aorta  arising  from  the  right  ventricle,  but  communicating 
with  the  left  by  an  aperture  in  the  sa?ptum ;  he  also  reports 
this  year  (1870)  a  case  of  almost  complete  separation  between 
the  sinus  and  infundibular  portion  of  the  right  lung,  the  aorta 
arising  from  both  ventricles. 

Green  (1867)  reports  a  case  of  malformation  of  the  heart 
with  absence  of  pulmonary  artery  and  the  aorta  springing 
from  the  right  ventricle.  The  s?cptum  ventriculorum  was  in- 
complete and  there  was  a  patent  foramen  ovale.  Vulpian 
(1868)  speaks  of  a  case  of  complete  obliteration  of  the  orifice 
of  the  pulmonary  artery.  Plickmann  (1869)  reports  a  case 
of  malposition  of  the  heart  and  transposition  of  the  auricles 
and  aorta;  there  was  absence  of  the  pulmonary  artery  and 
the  foramen  ovale  was  patent,  communicating  with  the 
ventricles,  with  lateral  transposition;  there  was  visceral 
cyanosis.  Again,  Hickmann  (1869)  reports  a  case  in  which 
there  was  transposition  of  the  viscera,  with  malformation 
of  the  heart,  the  i)ulmonary  veins  from  the  right  lung  enter- 


CARDIAMORPHIA  45 

ing  the  left  auricle  and  those  horn  the  left  lung  entering  the 
right  auricle. 

Allis  (1871)  reports  a  case  of  malformation  of  the  heart 
in  which  there  was  stenosis  of  the  pulmonary  artery,  per- 
foration of  the  ventricular  s?eptum,  and  dilation  of  the  right 
ventricle.  Rex  (1874)  reports  a  case  of  congenital  malforma- 
tion of  the  heart,  contraction  of  the  pulmonary  artery,  and 
deficient  ScTptum  ventriculorum,  the  aorta  originating  from 
both  ventricles.  There  was  no  cyanosis.  Janeway  (1877) 
reports  a  case  of  malposition  of  the  pulmonary  artery  anc^ 
aorta,  thrombosis  in  the  heart,  cerebral  embolism,  and  death 
from  intestinal  haemorrhage.  Archer  (1878)  reports  a  case 
in  which  there  was  a  congenital  band  across  the  origin  of 
the  aorta.  Stone  (1878),  from  among  his  clinical  cases,  re- 
ports a  congenital  malformation  of  the  heart  without  a  pul- 
monary artery. 

Peacock  (1876)  reports  stenosis  at  the  commencement 
of  the  conus  arteriosus,  at  the  right  ventricle,  and  at  the 
origin  of  the  pulmonary  artery.  The  aperture  in  the  saeptum 
ventriculorum  and  aorta  arose  partly  from  the  right  side. 
The  foramen  ovale  and  ductus  arteriosus  were  closed;  there 
had  been  cyanosis.  In  another  which  he  reports  (1880)  there 
was  great  stenosis  of  the  orifice  of  the  pulmonary  artery,  the 
aorta  arising  from  both  ventricles.  There  were  defects  in 
the  folds  of  the  foramen  ovale,  but  the  ductus  arteriosus  was 
closed. 

Lees  (1880)  reports  a  case  of  malformation  of  the  heart 
with  transposition  of  the  aorta  and  pulmonary  artery.  Shat- 
tock  (1881)  reports  atresia  of  the  aortic  orifice  in  an  infant, 
while  Ashley  (1881)  records  a  case  of  transposition  of  the 
aorta  and  pulmonary  artery  in  a  child  seven  months  old. 
One  of  the  most  interesting  cases  of  this  class  of  anomalies 
is  reported  by  Cronk  (1881).  The  aorta  arched  over  the 
right  bronchus  and  the  pulmonary  artery  closed  about  the 
semilunar  valves.    Abercrombie  (1882)  reports  a  case  of  con- 


46  THE  SURGERY  OF  THE  HEART 

genital  atresia  of  the  right  ventricle  with  patency  of  the  duc- 
tus arteriosus. 

Livingstone  (1883)  reports  on  a  congenital  communica- 
tion between  the  right  side  of  the  heart  and  the  beginning 
of  the  aorta.  Meyer  (1883)  mentions  a  case  of  cyanosis 
due  to  congenital  defects  of  the  aortic  orifice.  The  child 
lived  twenty-seven  days.  Bury  (1884)  reports  a  case  of  con- 
genital contraction  of  the  orifice  of  the  pulmonary  artery 
from  fusion  of  the  valves,  the  foramen  ovale  being  open. 
Again,  in  1887,  he  notes  a  case  of  congenital  malformation 
of  the  heart,  congenital  atresia  of  the  conus  arteriosus,  m- 
complete  saeptum  ventriculorum,  and  the  aorta  arising  mainly 
from  the  right  ventricle.  Little  (1880)  reports  a  case  of  ab- 
normity of  the  great  cardiac  vessels  with  absence  of  the 
superior  vena  cava.  Habershorn  (1887)  reports  a  congenital 
malformation  of  the  heart  and  kidneys  with  obliteration  of 
the  pulmonary  artery,  the  aorta  arising  from  the  right  ventri- 
cle. There  was  imperfection  of  the  saeptum  ventriculorum, 
and  the  lungs  were  supplied  from  the  aorta  by  a  large  ductus 
arteriosus  dividing  into  right  and  left  pulmonary  branches. 
There  was  a  horseshoe  kidney.  De  Renzi  (1889)  reports 
three  cases  of  abnormity  of  the  heart  and  one  of  the  great 
vessels  also.  Cadet  de  Gassicourt  ( 1890)  reports  a  case  of  mal- 
formation of  the  pulmonary  artery.  Howard  ( 1892)  reports  a 
case  of  congenital  malformation  of  the  heart  and  atresia  of  the 
pulmonary  artery  with  persistence  of  the  foetal  circulation. 
Stuertz  (1894)  mentions  a  case  of  obliteration  of  the  aorta. 
Nazarofif  (1895)  reports  a  congenital  deformity  of  the  heart 
(narrowing  of  the  cone  and  the  orifice  of  the  pulmonary 
artery  with  an  opening  on  the  intraventricular  and  interauric- 
ular  saeptum),  so  diagnosticated  during  life  and  confirmed 
by  autopsy.  Bovaird  (1895)  reports  two  cases  of  congenital 
cyanosis  due  to  stenosis  of  the  pulmonary  orifice  with  an 
interventricular  foramen.     Holt  (1895)  reports  a  malforma- 


Plate  VII. 


Traxs\-]-.rse  Section  of  Hzart,  ^/l  inch  from  Apex. 


Transverse  Section  of  Heart.  iVj  inches  from  Apex. 
(Anatomy  of  the  Heart.) 


CARDIAMORPHIA  47 

tion  of  the  heart  with  puhnonary  stenosis,  a  deficient  ventricu- 
lar saeptum,  open  ductus  arteriosus,  and  the  aorta  arising 
from  both  ventricles,  but  principally  from  the  right.  Caubet 
and  Baylac  (1896)  report  congenital  cyanosis  and  complete 
inversion  of  the  viscera.  Caille  (1896)  reports  a  case  of  trans- 
position of  large  vessels  in  the  heart,  as  does  Rolleston 
( 1897),  also  Gallaverdin  ( 1896)  reports  a  case  of  cardiac  mal- 
formation with  absence  of  the  pulmonary  orifice. 

Cavities. — That  a  human  being  may  live  indefinitely  with 
two,  three,  four,  five,  or  six  cavities  of  the  heart  has 
been  shown  by  the  various  reports  herein  mentioned.  Such 
facts,  however,  have  been  recognized  from  the  earliest  writ- 
ings on  anatomy.  Foster  (1846)  reports  a  heart  with 
only  two  cavities,  while  Crisp  during  the  same  year  men- 
tions a  heart  with  only  a  single  auricle  and  ventricle. 
Ramsbotham  (1846)  reports  the  heart  of  an  infant 
with  only  one  ventricle  and  auricle.  Hutchinson  (1853) 
mentions  a  case  of  rudimentary  right  ventricle,  giving  the 
heart  five  chambers.  Dalton  (1855)  reports  a  heart  in  which 
there  were  but  one  auricle  and  one  ventricle.  Clark  (1857) 
reports  a  case  of  but  a  single  heart.  Bradley  (1873)  reports 
a  tricoelian  human  heart,  while  Fenton  (1873)  reports  a  heart 
with  five  cavities.  Heineman  (1878)  writes  exhaustively  on 
a  malformed  heart  in  which  there  was  absence  of  the  right 
ventricular  cavity  with  occlusion  of  the  pulmonary  artery. 
Baldwin  (1879)  reports  a  most  interesting  condition  found 
in  a  case  of  malformation  of  the  right  heart.  There  was 
dropsy  involving  only  the  lower  extremity  and  half  of  the 
trunk.  Stone  (1881)  reports  a  case  of  tricoelian  heart  with 
insufficiency  of  the  ventricular  saeptum.  Turner  (1882)  re- 
ports a  malformed  heart  consisting  of  but  two  cavities. 
Schrotter  (1887)  mentions  a  case  of  dextrocardia,  while 
Shattock  mentions  a  heart  with  a  bifid  apex.  Holt  (1890) 
reports  a  congenital  malformation  of  the  heart  resembling 


48  THE  SURGERY  OF  THE  HEART 

dextrocardia,  with  entire  absence  of  the  sseptum  ventricu- 
lorum,  pulmonary  stenosis,  and  patent  foramen  ovale.  ]Mayer 
(1892)  records  a  double-hearted  freak. 

Cowan,  John,  on  obstruction  of  the  coronary  arteries,  Glas- 
gow Medical  Journal,  1902,  Ivii,  260-275;  2  fig. 

Dr.  Cowan  in  a  resume  states : 

1.  The  coronary  arteries  may  be  obstructed — (i)  at  their 
origin;  (2),  in  their  course. 

2.  If  the  obstruction  involves  a  main  artery  and  the  clo- 
sure is  gradual,  compensatory  enlargement  of  the  other  artery 
may  prevent  damage  to  the  cardiac  muscle,  but  perfect  com- 
pensation is  rare,  and  necrosis  or  fibroid  change  commonly  en- 
sues, if,  however,  the  closure  is  rapid,  sudden  death  is  the 
usual  result. 

3.  If  the  obstruction  involves  a  small  artery  no  compensa- 
tory arrangement  is  possible,  and  the  nutrition  of  the  cardiac 
muscle  will  suffer  whether  the  closure  is  rapid  or  gradual. 

4.  (a)  If  the  obstruction  is  partial  some  of  the  muscle  may 
degenerate  (granular  or  fatty  degeneration)  and  may  ulti- 
mately disappear  and  be  replaced  by  fibrous  tissue;  (b)  If  the 
obstruction  is  complete  some  of  the  muscle  will  become  ne- 
crosed (infarct)  and  the  patient  may  die  from  slow  cardiac 
failure  or  from  rupture  of  the  heart;  if,  however,  the  infarct 
is  of  small  size  healing  may  take  place  and  a  fibroid  scar  be 
ultimately  formed. 

For  other  abnormities  and  for  the  formation  of  the  heart 
and  its  great  vessels,  reference  may  be  made  to  the  bibli- 
ography. 


CARDIAMORPHIA  49 

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CARDIAMORPHIA  55 

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56  THE  SURGERY  OF  THE  HEART 

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Plate  VIII 


Traxsverse  Section  of  Heart,  2y^  inches  from  Apex. 


Transverse  Section  of  Heart,  3  inches  from  Apex. 
(Anatomy  of  the  Heart.) 


CARDIAMORPIIIA  57 

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CARDIAMORPIilA  59 

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6o  THE  SURGERY  OF  THE  HEART 

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64  THE  SURGERY  OF  THE  HEART 

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66  THE  SURGERY  OF  THE  HEART 

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Plate   IX. 


Transverse  Section  of  Heart,  4^^  inches  from  Apex. 
\  1 


Longitudinal  Section  of  Heart,  Din'iding  the  Right 
AND  Left  Heart. 


(Anatomy  of  the  Heart.) 


CARDIAMORPHIA  67 

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Howard,  W.  T.  Jr.,  Arch.  0}  Pcediat,  Philadelphia,  1892,  IX, 

22-30. 
Stembo,  L.,  Ein  Fall  von  Persistenz  des  Ductus  Botalli  bei  einem 

achtjahrigen  Knaben  mit  stark  ausgespruchenen  Trommel- 

schlagelfingern.     St.  Petersburg  med.  Woch.,  1894,  XI,  366. 
Passow,  Ein  Fall  von  Stenose  des  Conus  arteriosus  dexter  mit 

Defekt   im    Septum   Ventriculorum.     Charite-Ann.,    Berlin, 

1894,  XIX,  219-233. 
Kreisch,  E.,  Ein  Fall  von  hochgradiger  Verlagerung  des  Herzens 

in  der  rechte  Brustseite.     Bonn,  1894. 
Stuertz,  E.,  Berlin,  1894. 
Marchand,  F.,  Zur  Kenntnis  der  Embolic  und  Thrombose  der 

Gehirnarterien  zugleich  ein  Beitrag  zum  Casustik  der  prima- 

ren  Herztumoren  und  der  gekreuzten  Embolic.     Berlin,  klin. 

Woch.,  1894,  XXXI,  I,  36-62. 
Krumm,    F.,    Zur    Casuistik    gestielter    Herzpolypen,   Deutsches 

Arch,  jur  klin.  Med.,  1894-95,  LIV,  189-200. 
BoSTROEM,  E.,  Ueber  thrombenahnlichc  Bildungen  im  Herzens. 

Deutsches  Arch,  jiir  klin.  Med.,  1895,  LV,  219-239;  i  pi. 
Pic,  Deux  cas   de  malformation  congenitalc  du  coeur.     France 

med.,  1894,  Paris,  1895,  I,  842-845. 
Montalti,  a.,  Studio  clinico  c  teratologic©  sopra  casi  di  viziatura 

congenita  del  cuore,  Racogliatore  med.   Forli,  1895,  5  s.,  XX, 

25,  49>  85,  106,  125. 
Nazaroff,  D.  F.,  Vratch,  St.  Petersburg,  1895,  XVI,  323,  356,  387. 


CARDIAMORPIIIA  69 

Probyn-Williams,  R.  J.,  Malformed  Heart,  Tr.  of  the  Obst. 
Soc.  of  London  (1894),  1895,  XXXVI,  3. 

Acker,  G.  N.,  A  Case  of  Cardiac  Anomaly.  Arch.  0}  Pcediat., 
XII,  828. 

BovAiRD,  D.,  Arch,  oj  Pcediat.,  1895,  XII,  353-355. 

Chatin  and  Bret,  Note  sur  un  cas  de  maladie  bleue  (forme  tar- 
dive).    Province  med.,  Lyon,  1895,  IX,  246-248. 

FoRLANiNi,  C,  Un  caso  di  stenosi  dell'  arteria  polmonare  con  per- 
sistenza  del  dotto  arterioso  di  Botallo  e  tisi  pulmonare.  Pedi- 
alria,  Napoli,  1895,  m^  l^^l^- 

Holt,  L.  E.,  Arch,  oj  Pcrdiat.,  1895,  XII,  839-841. 

Jacobi,  a.,  Patent  Ventricular  Saeptum  in  a  Man  Twenty-nine 
Years  Old.     Ibid.,  834-838. 

Lemoine,  Un  cas  de  maladie  bleue.     Bull.  med.  du  Nord,  Lille, 

1895,  XXXIV,  350-353- 

McLauthlin,  H.  W.,  Case  of  Congenital  Cyanosis.  Med.  Age, 

1895,  XIII,  487-490- 
Meslay,  R.,  Communication  interventriculaire.     Bull,  de  la  Soc. 

anat.  de  Paris,  1895,  LXX,  98. 
RiCHARDiE,  H.,  La  forme  tardive  de  la  maladie  bleue.    Union  med., 

Paris,  1895,  3  s.,  LIX,  337-340. 
Simon,  J.,  La  cyanose  congenitale.      Presse   med.,  Paris,  1895, 

113- 

UcKE,  H.,  Ein  Beitrag  zur  Casuistik  der  Klappenanomalien  der 
Aorta.  Arch,  jiir  Path.  Anat.,  etc.,  Berlin,  1895,  CXL,  206- 
208. 

Apert,  E.,  Retrecissement  congenital  de  I'artere  puLmonaire  par 
endocardite  fetale,  perforation  de  la  cloison  interventricu- 
laire, inocclusion  du  trou  de  Botal,  absence  du  canal  art^riel. 
Bull,  de  la  Soc.  anat.  de  Paris,  1895,  LXX,  681-683. 

Bellot,  Malformation  cardiaque  fetale.     Ibid.,  757. 

AuGiER,  Retablissement  du  trou  de  Botal.  Gaz.  d.  hop.  de  Tou- 
louse, 1895,  IX,  228. 

Bonne,  C,  Malformation  congenitale  du  cceur.  Lyon  med.,  1895, 
LXXVIII,  2 1 1-2 1 7. 

Dickinson,  L.,  A  Case  of  Malformation  of  the  Heart  with  Haemo- 


70  THE  SURGERY  OF  THE  HEART 

philia.    Tr.  of  the  Clin.  Soc.  of  London,  1895,  XXVIII,  I38- 

140. 
Rosing-Hansen,  Case  of  Cyanosis  and  Congenital  Defect  of  the 

Heart.     Hosp.-Tid.,  Kjobenh,  1895,  4  R,  III,  977-990. 
EsHNER,    A.  A.,  Congenital  Malformation  of  the  Heart.     Phila. 

Poly  din.,  1895,  I^*  i43- 
Griffith,  W.,  Heart  with  a  Fibromuscular  Band.     Proc.  of  the 

Anat.  Soc.  of  Gr.  Brit,  and  Ireland,  London,  1896,  6-8. 
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152-158. 
Von  Berks,  A.,  Ein  interessanter  Fall  von  angeborener  Anomalie 

des  Herzens.     Wien.  klin.  Rundsch.,  1896,  X,  497-499. 
Freyberger,  L.,  Malformed  Heart  and  Great  Vessels.    Proceed- 
ings of  the  Anatomical  Soc.  of  Gr.  Brit.  &  Ireland,  1896,  19. 
Browiez,  On  Abnormal  Tendinous  Threads  in  the  Heart  and 

their    Eventual    Signification.     Medycyna,    Warszwa,    1896, 

XXIV,  621-623. 
CoHN,  I.,  Ueber  doppelte  Atrioventrikularostien.     Konigsb.  i.  pr., 

1868;  I  pi. 
Turner,  W.,  Jour.  0}  Anat.  and  Phys.,  London,  1895-96,  XXX, 

568. 
Przewoski,  E.,  Anomaliae  chordae  tendinae  cordis  humani,  valvula 

venae  cavae  superioris.     Pain  Towarz  Lek.,  Warszwa,  1896, 

XCII,  400-422;  3  pi. 
Packard,  F.  A.,  Report  of  a  Case  of  Imperfect  Closure  of  the  Au- 
ricular and  Ventricular  Saepta  in  a  man  Dead  at  the  Age  of 

Fifty  Years  from  Abscess  of  the  Brain.     Med.  News,  1896, 

LXIX,  235-238. 
Caubet  and  Baylac,  Arch.  med.  de  Toulouse,  1896,  II,  329-335. 
Rhenner,  G.,  Ueber  zrwei  falle  angeborener  Herzfehler.   Arch,  jur 

path.  Anat.,  etc.,  Berlin,  1896,  CXLVI,  540-546. 
Boije,  O.  a.,  a  Great  Abnormahty  of  the  Heart  in  a  Child  Three 

Days  Old.      Finiska  Laksallsk  handlg.,  Helsingsfors,  1896, 

XXXIII,  827-833. 
Gallois,  E.,  Forme  rare  de  malformation  cardiaque  cong^nitale. 

Lyon  med.,  1896,  LXXXIII,  469-476. 


CARDIAMORnilA  /I 

RoLLESTON,  Heart  Showing  a  Muscular  Band  Pressing  between 
the  two  jMuscuH  Pappillares  of  the  Left  Ventricle  and  Capable 
of  Acting  as  a  Moderator  Band.  Proc.  of  the  Anat.  Soc.  of 
Great  Britain  and  Ireland,  London,  1896-97,  pp.  21-23. 

Kalindero  and  Babes.  Un  cas  de  malformation  insignificante 
de  la  cloison  interventriculaire  aboutissant  a  une  Idsion  mor- 
telle.     Arch,  de  la  Soc.  med.  de  Bucarest,  Paris,  1896,  I,  481- 

485- 
Sidney,  A.,  Ueber  den  Abschluss  des    Sinus  coronarus  Cordis 

gegendenrechten  vorhof.     Anat.  Anz.,  Jena,  1896,  XXII,  274, 

277. 
HoBBS,  J.,  Relation  de  la  symphyse  cardiaque  avec  certains  aneu- 

rysmes  du  coeur.     Jour,  de  med.  de  Bordeaux,  1896,  XXVI, 

370- 
Geronzi,  G.,  Reperto  anatomo-patologico  ed  ossevazioni  sul  un 

raro  caso  di  anomaha  congenita  di  cuore.     Rijorma  med., 

Napoh,  1896,  XII,  pt.  3,  629-639. 
Caille,  a.,  Arch,  of  Peed.,  1896,  XIII,  756. 
Grant,  C.  G.,  A  Case  of  Ectocardia.    Brit.  Med.  Jour.,  London 

1896,  II,  1639. 
Moore  and  Molleson,  Notes  of  a  Case  of  Malformation  of  the 

Heart,  with  Description  of  Heart.     Intercolon.  Med.  Jour.y 

Melbourne,  1896,  I,  613-615. 
RoTCH,  T.  M.,  An  Unusual  Form  of  Congenital  Cardiac  Mal- 
formation.    Arch,  of  Pcediat.,  1896,  XIII,  906. 
Gaston,  J.,  Polype  du  coeur  gauche  avec  endocardite  auriculaire, 

insuffisance  tricuspide,  pleuresie  concomitante.     Gaz.  Med.  de 

Picardie,  Amiens,  1897,  XV,  122-124. 
Carpenter,  G.,  Two  Cases  of  Congenital  Malformation  of  the 

Heart.     PcEdiatrics,  1897,  III,  149-156. 
EiSENMENGER,  V.,  Die  angeborene  Defecte  der  Kammerscheide- 

wand  des  Herzens.     Zts.  f.  klin.  Med.,  Berhn,  1897,  XXXIII, 

1-28;  I  pi. 
Nammack,  C.  C,  Case  of  Congenital  Affection  of  the  Heart  in  a 

Woman  Thirty-six  Years  Old.     Med.  Rec,  New  York,  1897, 

LI,  564. 


72  THE  SURGtRY  OF  THE  HEART 

♦ 

MiRcoucHE  AND  BoNREAN,  Persistence  du  trou  de  Botal  chez 
une  femme  de  trente-cinq  ans.  Bull,  de  la  Soc.  Anal,  de  Paris, 
1897,  LXXII,  401. 

Reid,  G.  a.,  Note  on  an  Unusually  Heavy  Heart.  Lancet,  Lon- 
don, 1897,  I,  1466. 

Variot,  G.,  Sur  I'independance  des  malformations  congenitales  du 
coeur  et  de  la  cyanose.  Jour,  de  din.  et  de  therap.,  Paris, 
1897, V,  381-421. 

Variot,  G.,  Un  cas  de  cyanose  avec  dilatation  de  I'artere  pulmo- 
naire,  impossibilite  du  diagnostic  clinique  des  diverses  mal- 
formations cardiaques.  Jour,  de  din.  et  de  therap.  inf.,  Paris, 
1897,  V,  801-803. 

Young,  J.  C.,  A  Case  of  Defect  in  the  Ventricular  Saeptum  and 
Stenosis  of  the  Pulmonary  Conus  in  a  Man,  Thirty-two  Years 
Old.     Medicine,  Detroit,  1897,  IH,  455-458. 

Jacobson,  Anomalie  congenitale  du  coeur.  Bull,  de  la  Soc.  Anat. 
de  Paris,  1897,  LXXH,  435. 

Martin,  A.,  Anomalie  du  coeur.     Ibid.,  434. 

Rolleston,  H.  D,,  Pediatrics,  1897,  IV,  108-112. 

Coyon,  a..  Affection  congenitale  du  coeur,  aorte  naissant  du  ven- 
tricule,  artere  pulmonaire  naissant  du  ventricule  gauche,  per- 
foration du  trou  de  Botal,  persistance  du  canal  arteriel.  Jour, 
de  din.  de  therap.  in}.,  Paris,  1897,  V.,  505. 

Coyon,  A.,  Affection  congenitale  du  coeur,  transposition  des  arteres. 
Bull,  de  la  Soc.  Anat.  de  Paris,  1897,  XXL,  519-522. 

Turner,  W.,  Moderator  Band  in  Left  Ventricle  and  Tricuspid 
Left  Auriculoventricular  Valve.  Jour.  0}  Anat.  and  Phys., 
London,  1897,  98,  XXXII,  373-376. 

Fredrick,  M.,  Some  Malformations  of  the  Heart  and  Aorta. 
Cleveland  Med.  Gaz.,  1897-98,  XIII,  151-157. 

Jameson,  S.,  A  Case  of  Congenital  Heart  Disease.  Australas.  Med. 
Gaz.,  Sydney,  1897,  XVI,  216. 

Rudolf,  R.  D.,  Persistent  Foramen  Ovale.  Canad.  Pract., 
Toronto,  1897,  XXII,  879-883. 

Parsons  and  Keith,  The  Frequency  of  an  Opening  between  the 
Right  and  Left  Auricles  at  the  Seat  of  the  Foetal  Foramen 


CARDIAMORPIIIA  73 

■s 

Ovale,     Jour,  oj  Anat.  and  Phys.,  London,  1897-8,  XXXII, 

165-172. 

Simpson,  F.  V.,  Congenital  Abnormalities  of  the  Heart  in  the  In- 
sane. Jour,  oj  Anat.  and  Phys.,  London,  1897-98,  XXXII, 
679-686. 

Freyberger,  L.,  Anomalous  Truncus  Brachiocephalus  associated 
with  Aortic  Incompetence  and  Symptoms  Simulating  Aneur- 
ysm.   Tr.  of  the  Path.  Soc.  of  London,  1897-98,  XLIX,  44-46. 

Damsch,  O.,  Ueber  die  Bewegungsvorgangen  menschlichen  Her- 
zen,  Untersuchungen  in  Anschluss  an  die  Beobachtung  des 
freiliegenden  Herzens  in  einem  Fall  im  angeborenen  Sternal- 
spalte.     Leipsic  und  Wien,   1897. 

Chiari,  H.,  Ueber  Missbildungen  im  rechten  Vorhofe  des  Herzens. 
Beit.  z.  path.  Anat.,  Jena,  1897,  XXII,  i-io;  i  pi. 

Papillon  and  Suchard,  Anomalie  de  la  grande  valvule  de  I'ori- 
fice  mitral.     Bull,  de  la  Soc.  anat.  de  Paris,  1897,  LXXII,  556. 

PiTSCHEL,  W.,  Ein  Fall  von  Persistenz  des  Truncus  arteriosus 
communis.     Konigsb.,  1897. 

Kein,  G.,  Communication  interventriculaire  congenitale  sans 
cyanose,  mort  part  septicemic.  Bull,  de  la  Soc.  anat.  de  Paris, 
1897,  LXXII,  649-652. 

Cade,  A.,  Un  cas  de  malformation  cardiaque  congenitale  (absence 
de  I'aorte  pulmonaire).     Lyon  mid.,  1897,  LXXXVI,  155-162. 

Townsend,  C.  W.,  Three  Cases  of  Congenital  Heart  Disease. 
Boston  Med.  and  Surg.  Jour.,  1897,  CXXXVII,  493. 

Warner,  F.,  Congenital  Defect  of  Heart  and  Other  Parts,  Prog- 
nosis and  Management.  Internal.  Clinics,  Philadelphia, 
1897,  III,  157-165;  I  pi. 

AussAT,  A  propos  d'un  cas  de  retrecissement  congenital  de  I'artere 
puhnonaire  avec  perforation  interventriculaire.  Jour,  de 
din.  et  de  therap.  inf.,  Paris,  1898,  VI,  421-427. 

RuMMO,  G.,  Vizi  cardiaci  compento  o  multipli  cardiopatie  organ- 
iche  combriate  e  complicate.  Rijorma  med.,  Napoh,  1898. 
XIV,  pt.  I,  265. 

ZiNN,  Nachweis  einer  Anomalie  des  Herzens  durch  Rontgen- 
Strahlen.     Deut.  med.  Woch.,  1898,  XXIV,  vertheil,  41. 


74  THE  sur(;ery  of  the  heart 

EiSENMENGER,  V.,  Ursprung  der  Aorta  au5  beiden  Ventrickeln 

beim  Defect  des  Septum  Ventriculorum.     Wien.  klin.  Woch., 

1898,  XI,  25. 
Brooks,  H.,  Malformation  of  the  Heart.     Med.  Rec,  New  York, 

1898,  LIII,   134. 
Solomon,  L.  L.,  Louisville  Med.  Monthly,  1898-99,  V,  205-207. 
Della-Rovere,  D.,  Hypoplasie  de  i  linken  Herzens  mit  regelmas- 

siger  Entwicklung  des   Bulbes  aorticus,   andere  Anomalien 

der  Oeffnungen  und  Gefasse.     Centrbl.  }.  allg.  Path.  u.  path. 

anat.,  Jena,  1898,  IX,  209-230. 
Capitaix,  L.,  Un  cas  d'inversion  du  coeur  exclusivement.     Compt. 

rend,  de  la  Soc.  de  bid.,  Paris,  1898,  10  s.,  1104. 
Humphrey,  L.,  Congenital  Malformation  of  the  Heart,  System 

of  Med.  (AUbut),  New  York  and  London,  1898,  V,  697-726. 
Sailer,  J.,  Anomalies  of  Cardiac  Valves.     Ihid,  21 1-2 13. 
Ewald,  Cor  triloculare  biventriculare.     Berlin-  klin.  Woch.,  1898, 

XXXV,   1044. 
Packard,  F.  A.,  Bicuspid  Pulmonary  Valve.     Tr.  of  the  Path. 

Soc.  of  Phila.,  1898,  XVIII,  181-215. 
Gangitaxo,  F.,  Osservazioni  su  di  un  cuore  con  due  semilunari 

aortiche.     Clin.  med.  ital,  Milano,  1898,  XXXVII,  234-242. 
ScoFiELD,  A.   H.,   A   Case  of  Congenital  Malformation  of  the 

Heart.     Jour,  oj  the  Am.  Med.  Assn.,  1898,  XXX,  1332. 
Lewis,  H.  F.,  Aberrant  Tendinous  Cords  of  the  Heart.     Phila. 

Med.  Jour.,  1898,  II,  123-126. 
Cade,  A.,  Un  cas  de  malformation  cardiaque  congenitale  (absence 

de  I'artere  pulmonaire).  Mem.  et  compt.  rendus  de  la  med.  Soc 

de  Lyon  (1897),  1898,  XXXVII,  129-136. 
BoNVENUTi,  E.,  Dei  vizii  congeniti  di  cuore,  stenosi  del  cono  ar- 

terioso  destro,  communicazione  interventricolare  e  interauri- 

colare.     Clin.  med.  Ital.,  Milano,  1898,  XXXVII,  347-366; 

I  ch. 
Rau,  F.,  Cavemose  Angiom  in  rechtem  Herzverhof.     Arch.  /. 

path.  Anat.,  etc.,  Berlin,  1898,  CLIII,  22-24;  i  pl- 
Rau,  F.,  Offenbleiben  des  Ductus  Botalli.     Ibid,  25. 
Gallaverdin,  L.,  Province  med.,  Lyon,  1898,  XII,  391-393. 


Plate  X. 


View  of  Right  Heart. 


'^ 

1 

''''   JB^ 

^ 

% 

\    ■       ^_ 

Wf^ 

iW^' 

r 

bwv 

Incision  in  Right  Ventricular  Wall  Showing  Its 
Thickness. 


(Anatomy  of  the  Heart.) 


CARDIAMORPHTA  75 

Sequeira,  J.  H.,  Case  of  Congenital  Morbus  Cordis  with  Failure 
of  Physical  and  Mental  Development.  Huntcrian  Jour., 
London,  1898,  75. 

Variot,  G.,  Cyanose  liee  a  une  malformation  congenitalc  du  coeur 
chez  un  enfant  de  onze  ans  et  demi,  pere  mort  d'une  affection 
cardiaque  rheumatismal,  mere  vivante  atteinte  d'un  retrecis- 
sement  mitral.     Jour,  de  din.  et  de  therap.  in}.,  Paris,  1898, 

VI,  783-786. 

Griffith,  T.  W.,  Example  of  a  Large  Opening  between  the  Two 

Auricles  of  the  Heart  Unconnected  with  the  Fossa  Ovalis. 

Jour.  0}  Anat.  and  Phys.,  London,  1898-99,  XXXIII,  261. 
Swan,  J.  M.,  Fenestration  of  the  Right  Auricle.     Proc.  of  the 

Path.  Soc.  of  Phila.,  1898-99,  n.  s.,  II,  71. 
Smith,  F.  J.,  Malformed  Heart.     Proc.  of  the  Anat.  Soc.  of  Great 

Britain  and  Ireland,  1898-99,  pp.  5-9. 
Pepper,  W.,  Multiple  Congenital  Cardiac  Lesions.     Univ.  Med. 

Mag.,  1898-99,  I,  685-687. 
Eynard,  p.,  Un  cas  de  malformation  congenitale  du  coeur.     Mar- 
seille med.,  1899,  XXXVI,  111-117. 
Gerard,   G.,  Pathogenic  des  malformations  du  coeur,  en  par- 

ticulier  de  la  persistance  du   canal  arteriel.     Gaz.  d.  hop., 

Paris,  1899,  LXXII,  178-198,  208. 
Gerard,  G.,  A  Case  of  Patent  Sseptum  Interventriculare,  Patent 

Foramen  Ovale,  ^nd  Congenital  Stenosis  of  the  Pulmonary 

Artery,    coupled    with    an   Anomalous    Distribution    of   the 

Thoracic  Veins.     Ibid,  35-37. 
Massart,  E.,  Anomalies  cardiaques  rares.     Clinique  Brux.,  1899, 

XIII,  107. 
RizzARDi,  R.,  I  vizii  cardiaci  acquisiti  nei  bambini  in  rapporto 

alio   loro   etiologia,  sintomatologia,  e   prognostico.     Boll.  d. 

levator,  Bologna,  1899. 
Bonnet,  L.  M.,  Anomalies  de  I'orifice  de  I'artere  pulmonaire. 

Lyon  med.,  1900,  XCIII,  517-518. 
Caubet,  C,  Le  retrecissement  mitral  est  une  malformation  em- 

bryonnaire.     Arch.  prov.  de  med.,  Paris,  1900,  II,  193,  216, 

311.  324- 


^6  THE   SURGERY    OF   THE    HEART 

Larambergue,   Essai  sur  le   retrecissement   mitral   pur.   Paris, 

Vigot  f  re  res,  1900,  No,  511,  100  p. 
Riss,  R.,  Un  cas  de  malformation  cardiaque  congenitale.     Mar- 
seille nied.,  1900,  XXXVII,  402,  407. 
MoNCOROO,  Malformations  congenitales  multiples  du  coeur  d'ori- 

gine  vraisemblablement  heredosyphilitique.     Jour,  des  prac- 

ticiens,  Paris,  1900,  XIV,  513-516. 
Cotton,  A.  C,  Congenital  Cardiac  Malformation  with  Endo- 
carditis and  Anuria.     Arch.  0}  Poediat.,  1900,  XVII,  731-735; 

2  fig. 
Maccallum,  W.  G.,  Congenital  Malformation  of  the  Heart  as 

Illustrated  by  the  Pathological  Museum  of  the  Johns  Hopkins 

Hospital.     Johns  Hopkins  Bull.,  1900,  XI,  69-71;  8  fig. 
Hasenfeld,  a.,  Angeborener  combinirter  Herzfehler  mit  Blau- 

sucht  bei  einem  i8-jahr  Madchen.     Wien.  med.  Presse,  1900, 

XII,  1693-1696. 
Variot,  G.,  a  propos  des  malformations  congenitales  du  coeur  et 

de  leurs  signes  physiques.     Bull.,  et  mem.,  de  la  Soc.  med.  d. 

hop.  de  Paris,  1900,  3  s.,  XVII,  1209,  12 10. 
Ferranneul,  L.,  Anomahen  des  Korperbaues  bei  Kardioptosis. 

Zentrlhl.  /.  innere  Med.,  Leipsic,  1900,  XXI,  5-9. 
Starkin,  Zur  Diagnose  der  angeborenen  Herzfehler.     Arch.  }. 

Kinderh.,  1900,  XXVIII,  201-209. 
RuNNO,  G.,  Forme  rudimentali  anomale  e^complicate  della  stenosi 

mitralica.     Rijorma  med.,  Palermo,  1900,  I,  350-354. 
Henrard,  G.,  Un  cas  d'inversion  du  coeur.     Arch.  med.  Beiges, 

Bruxelles,  1900,  4  s.,  XV,  30-37. 
Bonner,  M.,  Ueber  offenen  Ductus  arteriosus.     Botalli,  Inaug. 

Dissert.,  Freiburg,   1901. 
ScHLEGMANN,  A.,  Ucber  zwei  Falle  von  angeborenen  Defect  im 

Septum  Ventriculorum  kombinirt  mit  hochgradiger  Stenose 

der  Lungenarterie.     Inaug.  Dissert.,  March,  1901. 


CHAPTER   IV 
ECTOCARDIA 

Displacement — a  putting  out  of  place;  applied  to  various 
organs.  Malpositions — Mains,  bad,  ponere,  to  place — the  im- 
proper or  abnormal  position  of  any  part  or  organ. 

Displacement  may  be  congenital  or  acquired,  or  it  may 
be  due  to  change  with  the  movements  of  respiration  or  bodily 
posture. 

Historical  (i  797-1 903). — Congenital.  The  heart  may  oc- 
cupy any  portion  of  the  thoracic  cavity  of  man.  It  has,  in 
two  cases,  been  found  in  the  abdominal  cavity,  the  devia- 
tion from  the  normal  type  being  greater  and  more  diversified 
in  the  congenital  displacements. 

The  heart  may  even  protrude  through  the  chest  wall, 
several  such  cases  having  been  recorded.  Abernethy,  in 
1793,  reported  an  unusual  case  of  transposition  of  the  heart 
and  distribution  of  the  blood-vessels  together  with  a  very 
strange  and  singular  formation  of  the  liver.  Lippington 
(1834)  recorded  a  case  of  transposition  of  the  heart  with 
complete  obliteration  of  the  gall  bladder.  Lyons  (1836)  re- 
ported a  case  of  malposition  of  the  heart  with  imperforate 
vagina,  and  O'Bryan  a  case  of  partial  ectopia  cordis  with 
umbilical  hernia. 

Smith  (1808)  recorded  a  case  in  which  the  heart  was  on  the 
right  side  without  transposition  of  other  viscera.  Bram- 
well  (1881)  reported  a  rare  form  of  congenital  misplacement 
of  the  heart  in  which  the  organ  was  situated  on  the  right 
side  of  the  body,  and  in  which  the  liver  remained  on  the  right 

77 


78  THE  SURGERY  OF  THE  HEART 

side  of  the  body  in  its  natural  position.  Robinson  (1881) 
reported  a  case  of  transposition  of  the  heart  with  abnormal 
and  imperfect  development,  there  being  only  one  auricle  and 
one  ventricle.  Babcock  (1884)  recorded  a  most  remarkable 
case  of  dexiocardia.  Augyan  (1888)  gave  an  interesting 
account  of  a  case  of  dexiocardia  with  insufficient  bicuspid 
valves.  Huchard  (1888)  and  Holt  each  report  a  case  in 
which  the  apex  beat  was  in  the  abdominal  cavity,  the  heart 
being  there  also. 

Frangois-Franck  (1889)  mentions  a  novel  case  of  con- 
genital cardiac  ectopia.  Sandhoff  (1890)  reports  a  case  of 
congenital  dextrocardia  and  transposition  of  the  thoracic 
viscera.  Abrams  (1900)  professes  to  have  discovered  a  new 
physical  sign  in  dislocation  of  the  heart.  He  states  that 
gastroectatic  dyspnoea  and  pseudoangina  indicate  a  displaced 
heart.  Droog  (1894)  reports  a  case  of  congenital  dextro- 
cardia with  hernia  of  the  lung.  Perregaux  (1894)  records 
a  case  of  displaced  heart  in  a  new-born  infant.  There  was 
apparent  absence  of  the  right  lung.  It  died  of  suffocation. 
MacLennan  (1896)  speaks  of  a  case  in  which  there  was  dexio- 
cardia without  displacement  of  other  viscera.  Gerrard  (1896) 
reports  a  case  of  dextrocardia  with  the  apex  beat  four  inches 
and  a  half  to  the  right  of  the  ensiform  cartilage,  with  no 
impulse  at  its  normal  position. 

Pic  (1897)  reported  a  case  of  pleural  efifusion  in  which 
the  differential  diagnosis  involved  congenital  dextrocardia. 
Morgagni  recorded  a  case  of  ectopia  cordis  congenita.  Barna- 
do  (1897)  recorded  a  case  of  ectopia  cordis  with  a  fissure 
in  the  sternum. 

Oki  (1898),  of  Tokio,  gave  a  unique  description  of  a  mis- 
placed heart,  and  Duchamp  reported  a  case  of  dextrocardia 
with  general  visceral  inversion  in  which  he  applied  the  x  ray 
to  determine  the  diagnosis.  Stockton  (1897)  recorded  a  case 
of  phrenic  paralysis  with  transposition  of  the  heart.  Dalton 
(1898)   reported   a  case  of  dextrocardia  with   left   superior 


ECTOCARDIA  79 

vena  cava.  Michael  (1900)  mentions  a  case  of  dextrocardia 
complicating  chorea.  Fitzgerald's  (1900)  case  was  one  in 
which  the  apex  beat  was  below  the  angle  of  the  right  scapula. 

Murrell,  D.  E.  (1901),  in  a  personal  communication,  re- 
ports the  case  of  C.  F.  Smith,  twenty-four  years  old,  five 
feet  ten  inches  high,  with  the  chest  well  developed  and  of 
even  conformation,  measuring  thirty-nine  inches  on  inspira- 
tion and  thirty-five  inches  on  expiration.  The  apex  beat 
of  the  heart  was  two  inches  to  the  left  of  the  right  nipple 
and  the  same  distance  below  that  point,  the  impact  being- 
most  distinct  at  the  lower  border  of  the  sixth  rib.  This 
condition  was  discovered  several  years  ago  in  examining 
his  chest  for  an  attack  of  pneumonia,  at  which  time  he  said 
he  had  known  for  some  time  previous  that  his  heart  did  not 
beat  where  other  people's  did.  There  was  no  effusion  then 
to  account  for  the  displacement  and  no  previous  history 
of  any  trouble  about  the  chest.  His  health  was  good  and  the 
dextrocardia,  no  doubt,  was  congenital.  He  was  a  bolt- 
maker  by  occupation. 

Acquired  Malpositions. — The  position  of  the  heart  may  be 
changed  suddenly  (as  by  trauma)  or  the  change  may  be 
gradual,  most  frequently  the  latter.  If  sudden,  it  is  due  to 
the  sudden  change  in  the  shape  of  the  chest,  or  haemorrhage 
into  it,  or  both. 

If  slowly  changed,  it  may  be  due  to  numerous  causes, 
such  as  aneurysm  of  the  arch,  empyema  or  hypertrophy,  di- 
rect or  indirect  pressure  from  the  accumulation  of  hard  or 
soft  fluids  within  the  thoracic,  mediastinal,  or  abdominal  cav- 
ity, or  tumor  growth  of  the  hard  or  soft  tissues  entering  into 
the  formation  of  either  of  these  cavities  or  their  contents. 

A  frequent  cause  in  changing  the  position  of  the  heart 
is  found  in  curvature  of  the  spine.  Stokes  (1831)  records 
a  case  of  probable  dislocation  of  the  heart  from  violence. 
Curran  (1862)  reports  one  of  malposition  of  the  heart  result- 
ing from  collateral  disease  or  visceral  derangement;  Green- 


80  THE  SURGERY  OF  THE  HEART 

ough  one  in  which  the  heart  was  displaced  to  the  right  side 
as  a  result  of  disease  of  the  right  lung. 

Brackenridge  (1880)  §ave  a  clinical  lecture  on  pulmon- 
ary phthisis  with  fibroid  contraction  of  the  right  lung,  dis- 
placement of  the  heart  upward  and  to  the  right,  angular 
bending  of  the  aorta,  and  dilatation  of  the  angle,  simulating 
a  considerable  aneurysm.  Lambert  (1880)  recorded  a  case 
of  traumatic  cardiac  hernia.  McSherry  (1886)  recorded  a 
case  of  displacement  of  the  heart  to  the  left  due  to  contrac- 
tion of  the  lung  on  that  side.  Nedwill  (1887)  records  one 
of  extreme  displacement  of  the  heart  from  the  left  to  the 
right,  from  purulent  efTusion  into  the  left  pleura.  Kukharski 
(1888)  mentions  complete  transposition  of  the  heart  to  the 
right  half  of  the  thorax,  following  atelectasis  of  the  right 
lung.  Lannelongue  (1888)  wrote  of  ectocardia  and  its  cure 
by  autoplasty.  Hawkins  (1890)  mentions  a  case  of  displace- 
ment of  the  heart  to  the  right  side,  the  other  viscera  being 
normal  in  position.  There  was  pulmonary  stenosis  with  re- 
gurgitation. McGee  reports  a  case  of  acquired  dextrocardia. 
Hall  (1898)  reports  one  due  to  lung  disease.  Satterthwaite 
(1899)  reports  one  due  to  lateral  curvature  of  the  spine; 
Wilson,  one  with  functional  irregularity  due  to  pleuritic  ef- 
fusion. Barbier  (1900)  reports  a  case  of  dextrocardia  re- 
sulting from  pulmonary  tuberculosis.  Leusser  (1902)  con- 
siders movable  heart  and  offers  various  suggestions  for  its 
relief.  Lannelongue  (1901)  reports  his  observations  on  a 
successful  operation  for  ectocardia  performec  in  1888. 
Beeson,  C.  F.  (1903),  records  a  case  of  displacement  of  the 
heart  due  to  aneurysm  of  the  descending  aorta. 

Cardiaptosis.— Abrams  (A^.  Y.  Med.  Journal,  Sept.  5,  1903, 
p.  484),  considers  the  downward  falling  of  the  heart  (non- 
congenital)  due  to:  i,  increased  size  and  weight  of  the  heart; 
2,  aneurysms  and  new  growths  that  displace  the  heart  down- 
ward; 3,  adhesions  pleural  and  pericardial. 


ECTOCARDIA  8l 


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84  THE  SURGERY  OF  THE  HEART 

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I 


Plate    XL 


Anterior  A'iew  of  Left  Heart  Showing  Incision  in 

Apex. 


Penetrating    Incision   of   Left   A'entricular    Wall 
Showing  Its  Thickness. 

(Chapter  on  Wounds  of  Heart.) 


ECTOCARDIA  85 

Becker,  E.,  Ueber  Dexicardie.    Jena,  1891. 

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25^253. 
Graanboom,  Ein  FaU  von  Dextrocardie  mit  Transposition  von 

alien  grossen  Gefassen.     Ztschr.  }.  klin.  Med.,  Berlin,  XVIII, 

1890-91,  185-192. 
EwART  AND  Bennet,  Case  of  Dexiocardia.     Tr.  of  the  Med.  Soc. 

of  London,  XIV,  1890-91,  438. 
Arnaud,  H.,  Compt.  rend,  de  la  Soc.  de  biol.     Paris,  1891,  9  s., 

Ill,  4-8. 
Inches,  P.  R.,  Maritime  Med.  News.     Hahfax,  III,  1891,  63. 
ScHOTT,  Deut.  med.  Ztg.     Berhn,  XII,  1891,  409-413. 
Varsi,  T.,  Ann.  de  VAsist.  Pub.,  Buenos  Aires,  II,  1891,  1892, 

46-58;  I    pi. 
Tauszk  and  Vas  Adatok,  a  sziv  helyzetvaltozasahoz.     Orvosi 

hetil.     Budapest,  1891,  XXXV,  14,  28,  43,  67. 
ScHOTT,  Zur  Kasuistik  der  kongenitalen  Dextrocardie.     Veroj- 

jentl.  d.  Hufeland.    Gesellsch.  in  Berlin,  Balneol-Gesellsch., 

XIII,  1 89 1,  3c^45. 
Salaghi,  S.  S.,  Exocardie,  appareil  pour  le  traitement  mecanique 

de  diverses  maladies,  methode  employee.     Bologne,  1891. 
Berwald,  Ein  Fall  von  Dextrocardie.     Berlin,  klin. 


86  THE  SURGERY  OF  THE  HEART 

Heicmann,  Ueber  eine  Anomalie  der  Lage  des  Herzens,     Berl. 

klin.  Woch.,  XXIX,  1892,  188. 
Bard,  L.,  Refoulement  du  cceur  a  droite  et  extrocardie  congenitale. 

Lyon  med.,  LXXI,  1892,  583;  1893,  LXXII,  15. 
Heyse,  Ein  Fall  von  hochgradiger  Verlagerung  des  Herzens  nach 

der  linken  Seite.     Deut.  Med.  Woch.,  Leipsic  und  Berlin, 

XIX,   1893,   1064-1068. 
Droog,  E.  a.  M.,  Nederl.  Tijdschr.  Geneesk.  Amst.,  1894,  2  R., 

XXX,  pt.  I,  872-80. 
Perregaux,  G.,  Bull,  de  la  Soc.  anal,  de  Paris,  LXIX,  1894,  968- 

971. 
Kreisch,  E.,  Ein  Fall  von  hochgradiger  Verlagerung  des  Herzens 

in  die  rechte  Brustseite.     Bonn,  1894. 
Storen,  E.,  Et  tifaelde  af  medfedt  dextrokardi.     Norsk.  Mag. 

f.  Laegevidensk.,  Christiania,  1894,  4  R  X,  93-97. 
LiviERATO,  P.  E.,  Spostamento  paradosso  del  cuore.    Arch.  ital. 

di  din.  med.,  Milano,  XXXIII,  1894,  38-41. 
GoRYANSKi,  G.  I.,  Sluchal  situs  cordis  transpositus  Bolnitsch. 

Gaz.  Botkina,  St.  Petersburg,  1895,  VI,  369,  374. 
Imotana,  E.,  Zur  jungsten  Demonstration  eines  Falles  von  Ectopia 

Cordis.     Wien.  med.  BL,  XVII,  1894,  191. 
ScHMiD-MoNNARD,   Vorstellung   eines   Falles   von   Dextrocardie 

ohne  Situs  Viscerum  inversus.     Munch,  med.  Woch.,  XLI, 

1894,  584. 
Spaink,  p.  F.,  Een  Gaval  van  Dextrocardie.     Geneesk.  Courant, 

Tiel,  LXVIII,  1894,  No.  25. 
Aroz-Afaro,  G.,  Un  caso  de  esclerosis  pulmonar  con  dextro- 
cardia.    Rev.  de  la  Soc.  Med.  Argent.,  Buenos  Aires,  1895, 

IV,  73-80. 
Passelt,  Deutsch.  Arch.  }.  klin.  Med.,  Oct.  25,  1895. 
Campbell,  G.  G.,  Cardiodextria.    Montreal  Med.  Jour.,  XXIV, 

1895-96,  515. 
Von  Nadeskay,  Anatom.  Anz.,  Jena,  XII,  1896,  269-272. 
Maclennan,  W.,  Brit.  Med.  Jour.,  London,  1896,  II,  1314. 
Bari,  a.  E.,  Blntsch.  Gaz.  Botkina,  St.  Petersburg,  VII,  1896, 

721-758. 


ECTOCARDIA  Sj 

SoBiERAjczYK,   A.,   Zur   Casuistik   der   Dextrocardie   nebst   Be- 

schreibung  eines  diesbeziiglichen  neuen  Falls.     Berlin,  1896. 
Steiner,  T.,  Ueber  angcborcne  und  erworbene  Dextrocardie  in- 

folge    rechtsseitiger    Schrumpfungspleuritis.     Berlin,    1896. 
Grant,  C.  G.,  A  Case  of  Extocardia.    Brit.  Med.  Jour.,  London, 

1896,  II,  1639. 
Haines,  Brooklyn  Medical  Journal,  March,  1896. 
Fernet,  Un  cas  d'ectopie  cardiaque  (dextrocardie)  sans  inversion 

des    visceres,    interpretation    pathogenique.     Bull,    et   mem. 

de  la  Soc.  med.  d.  hop.  de  Paris,  XIII,  1896,  873-875. 
Gerrard,  p.  N.,  a  Case  of  Dextrocardia.     Lancet,  London,  1896, 

I,  1060. 
Petit,  L.  H.,  Ectopic  cardiaque  a  droite  consecutive  a  une  pleu- 

resie  droite.     Bull,  et  mem.  de  la  Soc.  med.  d.  hop  de  Paris, 

XIV,  1897,  989-994. 
Petit    et    Ravant,    Dextrocardie    isolee    d'origine    congenitale. 

Ibid,  195-200. 
Benedikt,  M.,  Beobachtung  und  Betrachtungen  aus  dem  Ront- 

gen  Kabinette  der  Verdrehungen  des  Herzens.     Wien.  med. 

Woch.,  XLVII,  1897,  369. 
Pic,  a.,  Province  med.,  Lyon,  XI,  1897,  30S. 
Vehsemeyer,   Ein  Fall  von  congenitaler  Dexiocardie,  zugleich 

ein  Beitrag  zur  Verwerthung  der  Rontgenstrahlen  der  innern 

Medicin.     Deut.  med.  Woch.,  Leipsic,  XXIII,  1897,  180;  i  pi. 
MuGGiA,  A.,  Morgagni,  Milano,  XXXIX,  1897,  202-210. 
Holt,  L.  E.,  Med.  News,  LXXI,  1897,  769. 
Pascheles   and  Paltauf,   Ein  Fall  von  Dextrocardie.     Wien. 

klin.  Rundschau,  XI,  1897,  473. 
Revello,  R.,  Spostamenti  del  cuore.     Pammatone,  Genova,  1897, 

I,  No.  3,  68-76. 
AucHE  ET  BouYER,  Dextrocardie  pure  sans  inversion  generale. 

Jour,  de  med.  de  Bordeaux,  XXVII,  1897,  413-415. 
CocHEZ,  A.,  L'ectopie  du  coeur  a  droite  consecutive  a  la  pleuresie 

droite.     Gaz.  d.  hop.,  Paris,  LXX,  1897,  514-542. 
Barnado,  G.  F.,  Jour,  of  Anat.  and  Phys.,  London,  XXXII, 

1897-98,  325-333- 


88  THE  SURGERY  OF  THE  HEART 

Capitan,  L.,  Un  cas  d'inversion  du  coeur  exclusivemcnt.     Compt. 

rend,  de  la  Soc.  de  bioL,  Paris,  V,  1898,  1104. 
Caporali,  R.,  Sulla  dislocazione  funzionale  del  cuore.     N.  Riv. 

din.  terap.,  Napoli,  I,  1898,  400-408. 
McGee,  J.  H.,  Intercol.  Med.  Jour.,  Melbourne,  III,  1898,  662- 

664. 
Hall,  J.  N.,  Med.  Fortnightly,  St.  Louis,  XIII,  1898. 
Oki,  K.,  Tokyo  Iji-Shinshi,  1898,  2126-2128. 
Green  and  Rothrock,  A  Case  of  Concentric  Displacement  of 

the  Heart  to  the  Right  presenting  some  Unusual  Features. 

Phila.  Med.  Jour.,  1,  1898,  563. 
DucHAMP,  Loire  med.,  St.  Etienne,  XVII,  1898,  87-91. 
UsoFF,  P.,  Rare  Case  of  Displaced  Heart.     Med.  Obozr. ,Mosk., 

XLIX,  1898,  546-550. 
Stockton,  C.  G.,  Tr.  of  the  M.  Assn.  of  Central  N.  Y.,  1897, 

Buffalo,  1898,  134. 
Berend,  M.,  a  Case  of  Congenital  Dextrocardia.     Gyermekgyo- 

gasazt,  Budapest,  1898,  16. 
RuMMO,  G.,  Sulla  cardioptose  primo  abbozzo  anatomo-clinico. 

Arch,  di  med.  int.,  Palermo,  1898,  I,  161-183. 
Westermayer,  E.,  Untersuchungen  iiber  die  passiven  Verlager- 

ungen  des  Herzens.     Festch  z.  Eroffn.  d.  n.  Krankenh.  d. 

Stadt  Numb.,  1898,  471-481. 
Dalton,  N.,  Tr.  of  the  Path.  Soc  of  London,  1898-99,  I,  41. 
Ferrannini,  a.,  Le  dislocazioni  del  cuore  studiate  con  un  metodo 

cardiotopo-megetometrico.     Lavori  d.  cong.  di  med.  int.,  1898; 

Roma,  1899,  IX,  358-364. 
Determann,  H.,  Demonstration  der  Verschiebung  des  Herzens 

bei  Lagerveranderungen  des  Herzens  mittels  des  Rontgenver- 

fahrens.     Verhandlimg  d.  Cong.  j.  innere.  Med.,  Wiesb.,  1899, 

XVII,  606-610;  I  pi. 
Satterthwaite,  T.  E.,  N.  Y.  Med.  Jour.,  LXX,   1899,  469- 

475- 
Leo,  H.,  Ueber  einen  Fall  von  Dexiocardie.     Jahrb.  }.  Kinderh., 

Leipsic,  1899,  n.  F.,  i,  427-430. 

Lepine,  R.,  Dextrocardie  causee  par  la  retraction  du  poumon  droit 


ECTOCARDIA  89 

consecutive  a  une  peribronchite  syphilitique  avec  adherences 
pleurales.    Bull,  et  mem.  de  la  Soc.d.  hop.  de  Paris,  1899,  3  s., 

XM,  497-499- 
Fraxcois-Franck,   Nouvelles   recherches   sur  un   cas  d'ectopie 

cardiaque  (ectocardie)  pour  servir  a  I'etude  du  pouls  jugu- 

laire  normal  et  d'une  variete  de  bruit  de  galop.     Arch,  de 

phys.  norm,  et  path.,  Paris,  1899,  I,  70-87. 
Bernheim,  S.,  Les  ectopies  cardiaques.     Independ.  med.,  Paris,  V, 

1899,  313-315. 
G.AJRXiER,  Un  cas  de  dextrocardia  avec  autopsie.     Presse  mid., 

Paris,  II,  1S99,  15-18;    Le  anomaHe  antropologiche  nei  car- 

dioptosci.  Arch,  ital  di  med.  int.,  Palermo,  II,  1899,  x,  1^$- 

156. 
MuLLiCK,  S.  K.,  Case  of  Dextrocardia,  Tr.  of  the  Med.  Soc.  of 

London,  XXIII,  1899-1900,  345. 
Fremmer,  J.,  Seltene  Falle  in  der  Privatpraxis,  2  Falle  von  Dextro- 

cardie.     Pest.  Med.-chir.,  Presse,  Budapest,  'KXXVl,   1900, 

985-989. 
Crispino,  M.,  Riforma  med.,  Palermo,  III,  1900,  436. 
Lo^VTixTHAL,  H.,  Ztsch.  }.  klin.  Med.,  XLI,  1900,  130-136. 
Wilson,  F.  C,  Memphis  Med.  Monthly,  XX,  1900,  458-468. 
Bailbeer,  H.,  Bull,  et  mem.  de  la  Soc.  med.  des  hop.  de  Paris,  1900, 

3  s.,  X\'II,   187-191. 
ScHMELiNSKY,  Fall  von  Dextrocardie  mit  Persistenz  des  Ductus 

arteriosus  Botalli.    Deut.  med.  Woch.,  Leipsic,  XX\'I,  1900, 

Berlin,  194. 
Thomas,  H.  M.,  Demonstration  of  a  Case  of  Dextrocardia.     Chi- 
cago Med.  Recorder,  XIX,  1900,  318. 
Michael,  May,  Woman's  Med.  Jour.,  Toledo,  IX,  1900,  4-7. 
Kow"EXTHAL,  Die  Beweglichkeit  des  Herzens  bei  Lagen^erhan- 

derungen  des  Korpers  (Cardioptose).     Ztschr.  f.  klin.  Med., 

Berlin,  XI,  1900,  24-58. 
Henilard,  C,  Un  cas  d'in version  du  coeur.     Arch.  med.  beiges, 

Brux.,  XV,  1900,  30-37. 
Fitzgerald,  G.  C,  Brit.  Med.  Jour.,  London,  1900,  II,  664. 
Andre,  Dextrocardie  acquise.     Lyon  med.,  XCV,  1900,  417. 


90  THE  SURGERY  OF  THE  HEART 

Chapman,  H.  G.,  A  Case  of  Dextrocardia.    Intercolon.  Med.  Jour., 

Melbourne,  V,  1900,  309. 
Crisping,  M.,  Un  caso  di  destrocardia  congenita  pura.  Rijorma 

med.,  Palermo,  XVI,  1900,  pts.  436,  447,  459. 
Abrams,  Med.  Record,  New  York,  LVIII,  372-374. 
Plessi,  D.  R.,  Note  vole  spostamento  del  cuore  de  essudato  pleu- 

rice.     Gazz.  d.  osp.,  Milano,  XXII,  1901,  117-119. 
Weinberger,  M.,  Seltener  Fall  von  Verlagerung  des  Herzens  in 

die  rechte  Brusthohle.     Wien.  klin.  Woch.,  XIV,  1901,  129. 
Monks,  E.  H.,  Brit.  Med.  Jour.,  London,  1901,  I,  514. 
Chapgst-Prevost,  De  I'inversion  du  cceur  chez   un  des  sujets 

composants  un  monstre  double  autositaire  vivant  de  la  famille 

des  pages.     Compt.  rend,  de  VAcad.  d.  sc,  Paris,  CXXXII, 

1901,  223-225. 
MuRRELL,  D.  G.,  Railway  Surg.,  Dec,  1901,  p.  212. 
Leusser,  Munchener  med.  Woch,  July  i,   1902;  also  American 

Medicine,  Oct.  25,  1902. 
Lannelgngue,   Compt.  rend,  de  VAcad.  d.  sc,  Paris,  CXXXII, 

1901,  225. 
Beeson,  C.  F.,  American  Medicine,  1903,  p.  379. 


CHAPTER   V 
GUNSHOT,    LACERATED,  AND    INCISED   WOUNDS 

Wounds  of  the  heart  are  of  many  characters  and  degrees. 
Before  the  use  of  firearms,  daggers,  spears,  and  arrows  were 
most  common,  but  since  the  introduction  of  firearms  it  is 
probable  that  injuries  of  the  heart  are  more  frequently  due 
to  their  use. 

Historical  (i 552-1903). — Pare,  in  1552,  was  one  of  the 
first  to  refer  to  the  statement  that  heart  wounds  must  result 
in  instant  death.  He  saw  a  dueHst  run  two  hundred  paces 
before  falling  with  a  sword  wound  in  his  heart  large  enough 
to  admit  the  finger.  In  the  meantime  he  fought  his  antag- 
onist in  a  most  vicious  manner. 

Senac,  in  1749,  attributed  the  sudden  death  to  profuse 
bleeding,  while  Morgagni  thought  it  due  to  obstruction  of 
the  circulation  dependent  upon  the  distention  of  the  peri- 
cardium from  bleeding.  The  latter  author  reports  the  case 
of  Valsalva,  in  which  death  occurred  on  the  eighth  day  fol- 
lowing a  wound  of  the  right  ventricle. 

Aprilis  wrote  concerning  a  case  of  sword  wound  of  the 
right  auricle,  resulting  in  death  five  days  after.  (This  report 
is  in  the  first  medical  journal  ever  published,  1680,  Obs.  X,  a 
copy  of  which  is  now  in  possession  of  the  Surgeon-General 
of  the  United  States  Army.)  In  the  case  reported  by  Courtial 
(1705),  in  which  there  was  a  wound  of  the  left  ventricle,  the 
patient  walked  five  hundred  paces  and  lived  five  hours. 
Chastanet  (1783)  collected  many  cases  of  gunshot  wounds  of 
the  heart  from  the  records  of  Bonetus,  Morgagni,  and  others, 

91 


92  THE  SURGERY  OF  THE  HEART 

and  recorded  five  interesting  cases  of  his  own.  Lerouge 
(1792)  reports  the  case  of  a  soldier  who  resumed  his  voca- 
tion on  the  ninth  day  after  receiving  a  stab  in  the  right 
auricle,  and  died  suddenly  on  the  eleventh  day  at  a  cab- 
aret. 

The  case  of  Durande  (1798),  in  which  there  was  a  sword 
wound  of  the  right  ventricle,  did  not  terminate  fatally  until 
the  end  of  the  fifteenth  day.  This  patient  lived  longer  than 
the  usual  time  after  the  infliction  of  such  a  w^ound.  If  life 
is  prolonged  to  this  extent  recovery  usually  ensues.  In 
Babington's  case  of  the  same  year  (1798)  the  patient  lived 
but  nine  hours  after  having  received  a  bayonet  thrust  through 
the  entire  heart.  In  the  case  of  Frisi  the  patient  lived  ten 
days  after  having  received  a  wound  of  the  left  ventricle. 
Fournier  (1834)  reports  the  case  of  a  soldier  who  received 
a  gunshot  wound  in  the  breast  followed  by  profuse  haemor- 
rhage. He  was  thought  to  be  dead;  however,  he  rallied  and 
in  three  months  recovered,  dying  three  years  later,  when  the 
ball  was  found  buried  in  the  apex  of  the  heart. 

One  of  the  most  curious  cases  on  record  is  that  of  Holmes 
(1845),  ^vho  reports  an  accident  in  which  there  was  a  gun- 
shot wound  of  the  heart  without  perforation  of  the  peri- 
cardium. This  ball  entered  from  above,  passing  through  the 
base  of  the  heart,  clearing  the  pericardial  attachments.  Lav- 
ender (1851)  mentions  a  case  of  recovery  following  a  pene- 
trating wound  of  the  right  ventricle.  Carnochan  (1855)  re- 
ports a  case  of  gunshot  wound  of  the  heart  in  which  life  was 
protracted  for  eleven  days.  The  bullet  was  found  encysted 
in  the  heart's  substance. 

An  interesting  complication  of  gunshot  wounds  is  re- 
ported by  Prichard  (1855),  in  which  a  ball,  after  having  en- 
tered the  chest,  passed  through  the  heart  and  stomach. 
Purple  (1855)  reports  twelve  cases  of  gunshot  injuries  of  the 
heart  in  which  the  patients  survived  from  forty-four  hours 
to  six  years. 


GUNSHOT,    LACERATED,   AND    INCISED    WOUNDS  93 

Grant  (1857)  reports  a  case  of  gunshot  wound  in  which 
the  ball  after  entering  the  chest,  passed  through  the  heart  and 
stomach. 

In  the  case  of  Bullock  (1858)  the  patient  lived  four  days 
and  eighteen  hours  with  a  bullet  in  the  left  ventricle.  Andrew 
(i860)  showed  a  case  coming  under  his  observation  in  which 
a  fish  bone,  after  having  lodged  in  the  oesophagus  and  per- 
forated it  and  the  diaphragm,  entered  the  heart.  Croly 
(1864)  reports  the  finding  of  a  musket  ball  in  the  peri- 
cardium. 

The  reports  of  heart  injuries  in  the  American  civil  war, 
1861-65,  are  very  indefinite  and  unsatisfactory,  so  much  so 
that  they  will  be  given  but  passing  mention.  No  attempt, 
it  seems,  was  made  in  any  case  to  adopt  surgical  measures. 
U.  S.  A.  Report,  1865  to  1871,  No.  3,  S.  G.  O.  P.  91,  Medical 
Museum,  U.  S.  A.,  Spec,  1,837,  shows  a  gunshot  injury  to 
the  left  ventricle  and  right  auricle.  The  patient  survived 
seventy-five  minutes.  Medical  Museum,  U.  S.  A.,  Spec. 
2,639,  shows  a  gunshot  injury,  an  anteroposterior  perforation 
of  the  left  ventricle  near  the  sseptum,  with  instant  death. 
Medical  Museum,  U.  S.  A.,  Spec.  5,688,  shows  a  laceration 
of  the  right  ventricle  by  a  pistol  ball,  with  instant  death. 
Medical  Museum,  U.  S.  A.,  Spec.  5929,  shows  an  oblique 
perforation  of  the  anterior  wall  of  the  left  ventricle  by  a  small 
Derringer  ball;  cavity  not  open.  The  patient,  a  suicide, 
lived  twenty-seven  minutes.  Medical  Museum,  U.  S.  A., 
Spec.  5,949,  shows  a  pistol  shot  through  the  right  ventricle. 
The  patient  lived  fifteen  minutes.  Medical  Museum,  U.  S. 
A.,  Sec.  I,  Spec.  1,052,  shows  a  gunshot  wound  of  the  left 
ventricle.  Medical  Museum,  U.  S.  A.,  Spec.  5,648,  shows  a 
gunshot  wound  of  the  right  ventricle  and  auricle  causing  in- 
stant death.  Medical  Museum,  U.  S.  A.,  Sec.  i,  Spec.  4,870, 
shows  a  stab  in  the  apex  of  the  right  ventricle  by  a  jack  knife. 
The  wounded  man  ran  thirty  yards  and  Hved  twelve  minutes. 
Medical  Museum,  U.  S.  A.,  Sec.  i,  Spec.  504,  shows  a  mus- 


94  THE  SURGERY  OF  THE  HEART 

ket  ball  imbedded  between  the  innominate  artery  and  the 
descending  aorta. 

Hart  reports  a  wound  of  the  heart  of  a  deer  with  recov- 
ery. Robert  mentions  the  case  of  a  man  who  ran  sixty  yards 
and  lived  one  hour  after  having  been  shot  through  both 
lungs  and  the  right  auricle  of  the  heart.  Dudley  (1871)  re- 
cords the  case  of  a  man  who  lived  four  days  with  a  pistol 
ball  in  his  heart.  Ford  (1875)  speaks  of  a  case  of  recovery 
from  buckshot  wound  of  the  heart.  Vite  (1876)  in  his  min- 
utes speaks  of  the  tenacity  of  life  of  a  person  who  lived  four 
days  with  a  knife  wound  penetrating  the  chest  into  the  peri- 
cardial sac  and  passing  through  the  left  ventricle  of  the  heart 
into  the  opposite  wall. 

Among  the  cases  of  recovery  from  gunshot  wounds  of 
the  heart  is  that  of  Mellichamp  (1876).  Then  a  similar  case 
resulting  in  recovery  is  reported  by  Heil  (1878).  This  patient 
lived  twelve  months  after  having  received  a  stab  wound 
penetrating  the  aorta.  West  (1878),  of  Birmingham,  reports 
a  case  in  which  a  man  lived  four  years  and  a  half.  The 
autopsy  revealed  a  linear  scar,  half  an  inch  long,  in  the 
anterior  part  of  the  right  ventricle.  Gibney  (1878)  reports 
a  case  of  a  pistol  ball  passing  through  the  right  ventricle,  ssep- 
tum,  and  aorta.  Holly,  during  the  same  year,  reports  a  case 
of  pistol  shot  through  the  right  ventricle,  sceptum,  and  aorta. 
There  was  apparent  recovery  at  the  end  of  the  fourteenth 
day,  but  sudden  death  occurred  on  the  fifty-fifth  day.  The 
autopsy  revealed  the  ball  lying  in  the  left  ventricle. 

In  the  case  of  Boileau  (1879)  there  was  a  penetrating 
wound  of  the  heart,  involving  the  transfixion  of  both  ven- 
tricles, but  death  did  not  ensue  for  several  minutes.  Dun- 
ham's patient  (1879),  ^fter  having  received  a  bayonet  wound 
implicating  both  ventricles,  the  saeptum,  and  the  auricle, 
walked  several  yards  after  the  injury  and  died  at  the  end 
of  forty-six  hours.  In  another  case  death  did  not  result 
until  the  end  of  fifty-four  days.     Death  resulted  from  rupture 


Plate  XIT. 


Showing  Skewer  Penetrating  the  Two  Ventricles 
FROM  Right  to  Left. 


A  Direct  Penetrating  Knife  Wound  of  Left  Ven- 
tricular Wall. 

(Cliaptcr  on  Wounds  of  Heart.) 


GUNSHOT,    LACERATED,    AND   INCISED   WOUNDS  95 

at  the  point  of  lodgement  in  the  case  of  Robbins,  on  the 
eleventh  day.  Say  re  (1881)  reports  a  recovery  from  a  lacera- 
tion of  the  pericardium  and  contusion  of  the  heart. 

Simmons  (1882)  reports  a  case  in  which  a  pistol  ball, 
after  having  entered  the  heart,  had  fallen  into  the  inferior 
cava.  Randall  (1882)  reports  the  case  of  a  negro  boy  who 
died  sixty-seven  days  after  having  received  a  gunshot  wound 
of  the  chest,  from  overeating.  There  were  no  signs  of  heart 
wound.  The  autopsy  revealed  three  shot  in  the  base  of  the 
ventricle  and  two  in  the  auricle.  The  wounds  in  the  wall 
of  the  organ  were  all  firmly  healed. 

In  the  case  of  the  author  (1882)  there  were  numerous 
perforations  of  the  chest  by  buckshot,  one  having  passed 
through  both  auricular  walls  and  the  left  lung,  one  through 
both  ventricular  walls  and  the  left  lung,  and  one  through 
the  liver  and  the  abdominal  aorta,  all  from  right  to  left, 
with  all  these  wounds  the  patient  walked  ten  paces.  Ward 
(1883)  mentions  a  wound  of  the  chest.  The  ball  was  found 
lodged  beneath  the  two  layers  of  the  pericardium.  There 
was  laceration  of  the  wall  of  the  right  ventricle  and  of  a 
branch  of  the  anterior  coronary  artery,  causing  fatal  haemor- 
rhage into  the  pericardial  sac. 

"  I  have  in  my  possession  the  heart  of  a  man,  named 
John  Kelly,  containing  a  round  ball  which  lies  encysted  in 
the  apex  of  the  right  ventricle  and  which  was  received  twenty 
years  before  his  death.  There  is  conclusive  evidence,  how- 
ever, that  during  the  first  five  years  it  lay  near  the  right 
internal  jugular  vein  and  that,  having  at  length  made  its 
way  through  the  coats  of  this  vein,  it  dropped  into  the  ven- 
tricle and  finally  became  imbedded  in  the  wall?  of  the  heart 
at  its  apex.  It  remained  in  the  heart,  therefore,  fifteen  years, 
and  was  not  then  the  immediate  cause  of  death."  (Hamilton, 
"  Principles  and  Practice  of  Surgery,"  1886,  page  90.) 

Kravkofif  (1887)  reports  a  wound  of  the  left  ventricle  with 
recovery.     Peebles  (1892)  reports  a  pistol  wound  of  the  heart 


96  THE  SURGERY  OF  THE  HEART 

with  recovery.  Bell  (1894)  cites  a  case  of  recovery  following 
a  puncture  of  the  cardiac  wall  without  suture  after  the  clots 
had  been  removed  from  the  pericardium  by  incision. 

Sloan  (1896)  speaks  of  a  case  in  which  paracentesis  was 
undertaken  to  relieve  pericardial  effusion,  and  the  right  ventri- 
cle was  penetrated  and  300  grammes  of  liquid  blood  were  re- 
moved. There  was  rapid  improvement  for  twenty-four  hours, 
slower  after  that  until  recovery.  In  the  case  of  Nelson  ( 1896), 
who  was  shot,  the  x  ray  showed  the  ball  in  the  heart  moving 
with  each  pulsation.  Spencer  and  Tippet  ( 1896)  report  a  case 
of  punctured  wound  of  the  right  ventricle  of  the  heart 
through  the  second  intercostal  space,  with  severe  primary 
and  secondary  haemorrhages.  The  wound  healed  and  the 
patient  died  of  disease.  The  autopsy  revealed  the  location 
of  the  wound. 

Fisher  (1896)  shows,  in  a  case  he  reports,  that  a  rupture 
of  the  right  ventricle  of  the  heart  may  result  from  a  blow 
in  the  epigastric  region.  That  rupture  of  cicatricial  tissues 
of  the  heart  may  occur  is  shown  in  the  case  of  a  soldier  (a 
Michigan  sharpshooter)  who  received  a  bullet  wound  in  the 
heart  at  Spottsylvania,  Va.  He  died  suddenly,  two  years 
later,  in  such  a  way. 

WilHams  (1897)  reports  a  stab  wound  of  the  heart  and 
pericardium.  Suture  of  the  pericardium  was  performed,  with 
recovery.     The  patient  died  three  years  afterward. 

Hennen  states  that  a  case  came  under  his  observation 
in  which  a  bayonet  had  been  thrust  through  the  colon,  stom- 
ach, diaphragm,  lung,  and  right  ventricle,  and  the  man  lived 
nine  hours;  while  in  the  case  of  Jackson  the  patient  lived 
three  hours  and  a  half  and  made  depositions  to  the  name  of 
his  assassin,  after  having  received  two  shot  wounds  in  the 
chest,  one  passing  through  the  right  auricle.  Diemerbrock 
states  that  a  patient  walked  sixty  paces  and  lived  ten  days 
after  having  received  a  wound  of  the  right  ventricle. 

Needle  zcounds  of  the  heart  are  quite  common.     Among 


GUNSHOT,    LACERATED,   ANt)    INCISED   WOUNDS  9/^ 

those  reporting  such  accidents  are  Peck  (1852),  and  Pridborn 
(1856),  also  Wright  (1869).  Thomas  (1887)  reports  a  case 
of  suicide  with  a  needle,  while  Thompson  (1888)  reports  one 
with  a  pin.  Peabody  during  the  same  year  (1888)  found  a 
pin  imbedded  in  the  heart  of  a  cadaver.  Meacham  (1899) 
also  found  a  needle  in  the  heart  upon  autopsy. 

A  Sardinian  prince  met  instant  death  from  the  puncture 
of  the  right  ventricle  by  a  gold  needle  in  the  hands  of  his 
wife. 

Paget  (1897)  reports  the  case  of  a  man,  aged  thirty-one, 
who,  while  in  a  struggle,  received  a  needle  two  inches  long  in 
the  cardiac  region.  He  had  pain  on  the  following  day,  and 
worked  nine  days  with  continuous  pain  from  the  nipple  to  the 
axilla  and  down  the  inner  side  of  the  arm  to  the  elbow.  An 
operation  exposed  the  eye  of  the  needle,  which  moved  with 
each  pulsation  of  the  heart.  The  needle  was  withdrawn  and 
recovery  ensued.  In  the  case  of  a  girl  eleven  years  old,  a 
knitting  needle  entered  the  chest,  breaking.  An  operation 
found  it  penetrating  the  heart.  The  removal  was  followed 
by  recovery.  Callender's  patient  ( 1897),  in  attempting  to  com- 
mit suicide,  drove  a  needle  into  the  heart.  Indications  were 
those  of  a  disturbance  by  a  foreign  body.  By  an  operation  the 
pleura  was  opened,  as  was  the  pericardium  also ;  a  gauze  sponge 
was  lost  in  the  pleural  cavity  and  was  not  recovered.  The 
needle  head  was  brought  to  view,  but  by  strong  motion  of  the 
heart  had  been  thrown  completely  into  the  ventricle  and  was 
upright.  Pneumothorax  occurred  six  days  later.  The  patient 
left  the  hospital  in  four  weeks  in  perfect  health. 

Among  those  to  compile  tables  concerning  heart  wounds 
was  Purple  (1855),  who  reported  forty-two  cases  that  were 
immediately  fatal.  Twelve  of  these  were  due  to  gunshot. 
Otis  reports  twenty-one  cases  of  injuries  of  the  heart  in  the 
United  States  Army,  1865- 1870.  Eighteen  were  gunshot, 
two  incised,  and  one  an  arrow  puncture.  Holmes  and  Fisher 
(1881)  report  a  series  of  452  wounds  of  the  heart,  with  104 


98  THE  SURGERY  OF  THE  HEART 

immediate  deaths,  219  not  immediate,  72  recoveries,  and  57 
uncertain  as  to  time  of  death;  123  right  ventricle,  loi  left 
ventricle,  26  both  ventricles,  28  right  auricle,  13  left  auricle, 
7  saeptum  ventriculorum,  17  apex,  2  base,  16  whole  heart,  4 
right  heart,  5  left  heart,  2  coronary  artery,  57  uncertain,  and 
51  pericardium.  He  also  reports  a  series  of  cases  of  foreign 
bodies  in  the  heart,  such  as  needles.  One  entered  through 
the  sternum,  eight  by  the  oesophagus,  thirty  by  the  thorax, 
and  eight  by  an  uncertain  route. 

Fisher  enumerates  452  cases,  of  which  44,  with  10  re- 
coveries, were  punctured  wounds;  260,  with  43  recoveries, 
were  punctured  incised  wounds;  72,  with  12  recoveries, 
were  gunshot  wounds;  and  76,  with  10  recoveries,  were  con- 
tusions and  traumatic  rupture.  Olliver  and  Sanson  state 
that,  out  of  twenty-nine  cases  of  penetrating  wounds  of  the 
heart,  only  two  proved  fatal  in  forty-eight  hours.  In  the 
others  death  took  place  in  from  four  to  seventy-eight  days 
after  the  wound. 

Hill  records  a  case  in  which  he  extracted  a  needle  that 
had  been  forced  through  the  skin  into  the  heart.  Fouck  and 
Pramm  (1901)  report  a  case  of  suicide  in  which  a  man  stabbed 
himself  in  the  left  thorax  with  a  long  knife,  the  weapon  pene- 
trating the  pericardium  and  entering  the  left  ventricle,  after 
which  he  drew  out  the  knife  and  laid  it  on  a  table  near  by. 
The  weapon  was  apparently  perfectly  clean,  but  microchem- 
ical  examination  of  a  tiny  rust  fleck  on  the  blade  revealed 
the  presence  of  hsemin  crystals. 

Roswell  Park  (1902),  in  attempting  to  remove  what  he 
supposed  to  be  pericardial  fluid  with  an  aspirating  needle, 
removed  pus  from  an  abscess  cavity  in  the  wall  of  the  heart. 
(See  Chapter  on  Abscess  of  the  Heart.) 


GUNSHOT,    LACERATED,    AND    INCISED    WOUNDS  99 


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GUNSHOT,    LACKRATKI),    AND    INCISED    WOUNDS  IO3 

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1869,  IV,   209. 

Hart,  Med.  Rec,  New  York,  1870,  V.,  232. 

FiNNELL,  Stab  wound  of  the  Heart  and  instantaneous  death.    Med. 

Rec,  New  York,  1870,  V,  232. 
Fleming,  Wound  of  the  Heart.  Dublin  Quart.  Jour.  Med.  Sc, 

1870,  XLIX,  499. 

Whipham,  T,,  The  heart,  left  lung,  and  portions  of  the  costal  carti- 
lages of  a  man  who  shot  himself.     Tr.  Path.  Soc,  London, 

1870,  XXI,  92. 

West,  J.  F.,  On  wound  of  the  Heart  (thirty-four  cases),  St.  Thomas 
Hospital  Report,  London,  1870,  n.  s.,  I,  237-275. 

Kemper,  G.  W.  H.,  Remarkable  exertion  after  a  fatal  gunshot 
wound  through  the  heart.  Indiana  Jour.  Med.,  Indianapolis, 
1870-71,  I,  237. 

Roberts,  J.  B,,  Richmond  and  Louisville  Med.  Jour.,  Louisville, 

1871,  XII,  607-613. 

Dudley,  G.  F.,  Med.  Arch.,  St.  Louis,  1871,  VI,  23. 

Ross,  G.,  Case  of  wound  of  the  left  lung  and  heart.  Canada  Med. 
Jour.,  Montreal,  1871,  VII,  256-275. 

Callender,  W.  G.,  Removal  of  a  needle  from  the  heart.  Recov- 
ery of  the  patient.  Proc.  Roy.  Med.  and  Surg.  Soc,  London, 
1871-75,  VII,  116;  also  Med.  Chr.  Tr.,  London,  1873,  LVI, 
203-212.     Also  Med.  Times  and  Gaz.,  London,  1873,  I,  212. 

Stevens,  E.  B.,  Remarks  on  injuries  of  the  heart.  Cincinnati 
Lancet  and  Obs.,  1874,  XVII,  523-526. 

Goss,  F.  W.,  Wound  of  the  heart;  probably  from  a  knife.  Boston 
Med.  and  Surg.  Jour.,  1874,  XCI,  308. 

Knapp,  M.  L.,  Knife  wound  of  the  heart.  Med.  and  Surg.  Re- 
porter, Philadelphia,  1874,  XXX,  379. 

H.  R.,  Gunshot  wound  of  the  heart  not  immediately  fatal.  Indian 
Med.  Gaz.,  Calcutta,  1874,  IX,  65. 

Evans,  G.  H.,  Case  of  dilated  heart  from  valvular  disease.  Right 
ventricle  tapped  by  error,  not  only  without  harm,  but  with 
relief  of  the  symptoms.  Tr.  Clin.  Soc,  London,  1875,  VIII, 
169-172. 


104  THE  SURGERY  OF  THE  HEART 

Ford,  C.  L.,  Med.  Rec,  New  York,  1875,  X>  i73- 

ViTE,  J.,  Richmond  and  Louisville  Med.  Journal,  Louisville,  1876, 

XXI,  151. 
Mellichamp,  J.  H.,  Charleston  Med.  Journal  and  Rev.,  1876,  n.  s., 

IV.,  17-20. 
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X,  253-257.     Also  Trans.  Lyon  Med.,  1877,  XXVI,  50-54. 
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481-484. 
Renaud,  Gaz.  Med.  de  Paris,  1877,  p.  361. 
WiRTH,  R.,  Wound  of  the  heart.     Ohio  Med.  Recorder,  Columbus, 

1877,  I,  500-503. 

Gibney,  V.  P.,  New  York  Med.  Jour.,  1878,  XXVIII,  634-636. 

Heil,  Erichsen's  Surgery,  1878,  Vol.  I,  p.  626. 

West,  of  Birmingham.     Erichsen's  Sc.  and  Art.  of  Surg.,  Vol.  II, 

1878,  p.  624. 

O'Neill,  J.,  Remarkable  injury  of  the  heart.  Indian  Med.  Gaz., 
Calcutta,  1878,  XIII,  44. 

Ollivier  and  Sanson  have  collected  twenty-nine  cases  of  pene- 
trating wounds  of  the  heart  which  did  not  prove  fatal  in  the 
first  forty-eight  hours  after  injury.  Erichsen's  Sc.  and  Art 
of  Surgery,  Vol.  I,  1878,  p.  624. 

Jamain  collected  forty-eight  cases  in  which  people  have  lived  for 
considerable  time  after  having  wound  of  the  heart.  Time 
seven  hours  to  twenty  days.  Erichsen's  Sc.  and  Art  of  Sur- 
gery, VII,  1878,  p.  624. 

Bryant,  Gunshot  wounds  of  the  heart  are  always  fatal  although 
not  always  immediately. (?)  Practice  of  Surgery,  1878, 
p.  891. 

Hally,  F.  M.,  Med.  Rec,  New  York,  1878,  XIV,  476.  Also  Med. 
and  Surg.  Reporter,  Philadelphia,  1879,  XL,  188. 

Boone,  W.  H.,  Case  of  gunshot  wound  of  the  heart;  death  on  the 
thirteenth  day.  Am.  Jour.  0}  the  Med.  Sc,  Philadelphia,  1879, 
n.  s.,  LXXVIII,  589. 

Boileau,  J.  P.  H.,  Tr.  Path.  Soc.  London,  1879,  XXX,  278,  also 
Brit.  Med.  Jour.,  London,  1879,  I,  628. 


Plate  XIII. 


An    Oblique    Penetrating    Knife   Wound   of    Left 
Ventricular  Wall. 


A  Longitudinal  Penetrating  Wound  of  the  Heart, 

Showing  How  Wounds  of  the  PIeart 

]\L\Y  BE  Extra  Pericardial. 

(Chapter  on  Wounds  of  the  Heart.) 


GUNSHOT,    LACERATED,   AND    INCISED    WOUNDS  105 

Dunham,  Mr.,  A  case  of  bayonet  wound  implicating  both  ventri- 
cles, the  sa^ptum  and  the  auricle.  Patient  lived  forty-six  hours 
and  walked  some  yards  after  receiving  the  injury.  Agnew, 
Surg.,  Vol.  I,  424.  Perforating  shot  wound  of  the  left  ventri- 
cle, which  did  not  prove  fatal  for  fifty-four  days.  London, 
Lancet,    January,    1879. 

Rouse,  W.  H.,  Pistol-shot  wound  of  the  heart.  Michigan  Med, 
News,  Detroit,  1880,  III,  60. 

Robins,  M.  M.,  Med.  Rec,  New  York,  1880,  XVIII,  599. 

Duffel,  J.  E.,  A  man  lives  three  hours  after  being  shot  through 
both  lungs  and  the  left  auricle  of  the  heart.  New  Orleans 
Med.  and  Surg.  Jour.,  1880-81,  n.  s.,  VIII,  1145-1151. 

Sayre,  L.  a..  Bull.  New  York  Path.  Soc,  1881,  2  s.,  I,  6. 

Holmes,  Syst.  Surg.,  Vol.  I,  1881,  pp.  777-8. 

FiSHBOURNE,  J.  E.,  Gunshot  wound  case.  Lancet,  London,  1881 ; 
I,  851. 

Case,  A.  G.,  History  and  autopsy  of  a  wound  in  the  heart.  Pitts- 
burg Med.  Jour.,  1882,  II,  366-369. 

West,  J.  F.,  Suicidal  pistol  wound  of  the  pericardium,  heart  and 
stomach;  death    in    twenty-three    hours.     Lancet,    London, 

1882,  n,  55. 

Jones,  R.  E.,  Gunshot  wound.     Tr.  Miss.  M.  Ass.,  Jackson,  1882, 

XVI,   124. 
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1882,  XVII,  297. 

Simmons,  Gross.  Syst.  Surg.,  1882,  Vol.  II,  p.  381. 

Randall,  Dr.,  Tennessee.    Syst.  of  Surg.,  Gross,  1882,  Vol.  II,  382. 

Carwin,  F.  M.,  Remarks  on  cardiac  aspiration.     Med.  Rec,  New 

York,  1883;  XXIII,  263. 
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1883,  XXIII,    140. 

Ward,  S.  B.,  Med.  Ann.,  Albany,  1883,  IV,  169-175. 
Kronecker    and    Schmey.     Sitzungsberichted    Berhner   Akad, 

1884,  p.   87. 

AxFORD,  W.  L.,  Two  cases  of  injury  to  the  cardiac  valves  from  sud- 
den violence.     Med.  Rec,  New  York,  XXIII,  319. 


I06  THE  SURGERY  OF  THE  HEART 

Odenius,  M.  v.,  Skottsar  genon  hjartet  ett  bidrag  till  kammendo- 
men  om  det  lefvande  hjortets  lage  C.  r.,  perforation  du  coeur 
par  une  balle  de  revolver;  contribution  a  la  connaissance  de  la 
situation  du  coeur  vivant.  Nort.  Ark.  Med.,  Stockholm,  1884, 
XVI,  No.  20,  II,  6-12. 

DoDD,  A.,  Bayonet  wound  of  heart;  death  from  internal  haemor- 
rhage; necropsy.     Brit.  Med.  Jour.,  London,  1885,  I,  379. 

Von  Mosetig-Monhof,  Ueber  einen  Fall  von  Schussverletzung 
des  herzens.     Wien.  Med.  Presse,  1885,  XXVI,  179. 

Flynn,  E.  F.,  Wound  of  inferior  vena  cava  and  right  auricle,  death 
in  seventy-five  minutes.     Brit.  Med.  Jour.,  London,  1885,  I, 

594- 
Von  Hosslin,  R.,  Nadel  in  herzen.     Deut.  Archiv  }.  klin.  Med., 

1884-85,  XXVI,  588-595,  595-598. 

Duplaix,  Archiv.  de  Med.  Gen.,  1885. 

Neal,  J.  C,  Bullet  wound  of  the  heart.     Med.  Rec,  New  York, 

1885,  XXVII,  626. 

Chassaignac,  C,  Punctured  wound  of  the  heart.  New  Orleans 
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Miles,  A.  B.,  Gunshot  wound  of  the  heart.     Ibid,  113-118. 

Lebeuf,  L.  G.,  Penetrating  wound  of  the  heart.  New  Orleans 
Med.  and  Surg.  Jour.,  1885-86,  n.  s.,  XIII,  543. 

Michel,  J.  E.,  An  unusual  case  of  gunshot  wound.  Atlanta  Med. 
and  Surg.  Jour.,  1886,  XV,  40. 

Nicholson,  G.  F.,  Shot  wound.  Ball  passed  through  both  auri- 
cles and  both  lungs;  patient  lived  forty-two  hours.  Med. 
New's,  July  31,  1886,  123. 

HooPMAN,  S.  v.,  Gunshot  wound  of  the  heart.  Med.  Rec,  New 
York,    1886,   XXIX,    360. 

Kosteller,  B.,  Two  cases  of  wounds  of  the  heart.  Med.  Obozr., 
Mosk.,  1886,  XXV,  733-735- 

Nicholson,  G.  F.,  Gunshot  wound  of  the  heart;  patient  survived 
forty-two    hours   after  injury.     India  Med.  Gaz.,  Calcutta, 

1886,  XXI,    143. 

ScHULTE,  Drei  falle  von  verletzung  des  herzens  des  bulbes  aortae. 
Vrtljschr  f.  Gerichtl.  Med.,  Berlin,  1886,  XLIV,  308-311. 


GUNSHOT,    LACERATED,    AND    INCISED   WOUNDS  10/ 

Serra,  L.,  Ferita  d'arma  da  fuoco  con  lesions  del  cuorc  senza 
ferita  del  pericardio,  osservazione  fatta  in  un  caso  d'amicide 
per  doppio  sparo  d'  arma  de  fuoci.     Cagliara,  1886. 

Wyman,  H.  C,  Wound  of  the  heart.     Med.  Age,  Detroit,  1886, 

IV,  505-509- 

MoRKRjiTSKi,  Wound  of  the  heart.    Vratch,  St.  Petersburg,  1886, 

VII,  803. 
Thomas,  D.,  Lancet,  London,  1887,  I,  230. 
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Mosk.  sborinku,  St.  Petersburg,  1887,  18-20. 
Karlinski,  J.,  Contribution  to  knowledge  of  wounds  of  the  heart 

by  ricochet  firing.     Prazgl.  lek,  Krakow,  1887,  XXVI,  155- 

165. 
CuRRAN,  W.,  Survivance  after  gunshot  wounds  or  other  injuries 

of  the  heart.     Lancet,  London,  1887,  673,  723,  850. 
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heart  under  fire,  as  well  as  on  pressure  of  cold  steel.     Med. 

Press  and  Circ,  London,  1887,  XLIV,  27-50. 
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1887. 
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696. 
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d.  D.  Gesellschft.  Chit.,  Berlin,  1887,  XVI,  pt.  I,  61. 
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Gesellschft.  Chir.,  Berhn,  1887;  XVI,  pt.  I,  58-61. 


I08  THE  SURGERY  OF  THE  HEART 

FuRBiN,  Et  spallitta  Rimarchcvolc  toUeranze  di  ferite  al  cuore. 
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punctured  and  lacerated  wounds  of  the  heart.     Med.  Press 

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judiciaire.     Lyon,  1888. 
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mento,  sottura  del  cuore  nel  tossuto  di  cicatrice  gia  alia  fase 

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Rhode  Island  Med.  Soc,  1889,  III,  561-565. 


GUNSHOT,    LACERATED,    AND    INCISED   WOUNDS  IO9 

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no  THE  SURGERY  OF  THE  HEART 

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LuMMiczER,  J.,  Beitrage  zur  symptomatologie  der  verletzungen 
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GUNSHOT,    LACERATED,   AND    INCISED    WOUNDS  I  I  I 

SoURRis,  Lesion  indirecte  du  coeur  par  un  projectile  dc  guerre  et 

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1894,  XXXV,   1 5 18-15  20. 
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Med.  Jour.,  Lonndo,  1894,  II,  1427. 
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XXXVIII,  209-211. 
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XXII,  29-32. 
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des  herzens.     Vrtljschr  }.  Gerichtl.  Med.,  Berlin,  1896,  XI, 

16-46. 


112  THE  SURGERY  OF  THE  HEART 

Ruth,  Herzverletzung  mit  nicht  sofort  todlichen  ausgange.  Fried- 
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Pelkoff,  V.  N.,  Rare  case  of  gunshot  wound  of  the  heart.  Voy- 
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305-310. 

Hanna,  W.  J.,  Transfixion  of  the  left  ventricle  of  the  heart  by  a 
sharp  wire  with  a  second  wound  penetrating  the  wall  of  the 
ventricle.     Occidental  Med.  Times,  1896,  X,  440-442. 

PiSARZEWSKi,  G.,  Gunshot  wound  of  the  heart  terminating  in 
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721. 

Spencer,  W.  G.,  Punctured  wounds  of  the  right  ventricle  of  the 
heart.     Brit.  Med.  Jour.,  London,  1896,  II,  1129. 

Salomoxi,  Centralblat.j.  Chir.,  1896,  No.  51. 

Turner,  W.,  Remarks  on  wounds  of  the  heart  with  notes  on  a 
case  in  which  death  took  place  four  and  one  half  minutes  sub- 
sequently and  cicatrization  was  shown  post-mortem.  Brit. 
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Englemann,  Archiv  }.  d.  Ges.  Phys.,  1896,  XV,  119,  535. 

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One  of  the  Editors,  Paracentesis  with  striking  success  in  a  case 
in  which  death  was  imminent  from  over  distention.  Gould 
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Velpeau's  Open  Surg.,  Vol.  I,  by  Mott.  Crile  on  shock.  Ex- 
perimental, 1897,  p.  129.  Puncture  in  Chloroform-Syncope. 
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375- 

Williams,  D.  H.,  Patient  died  three  years  afterwards.  Med.  Rec, 
New  York,  1897,  LI,  437-439- 

Rehn,  The  successful  treatment  of  a  wound  of  the  heart.  Lancet, 
London,  1897, 1,  1306.  Death  in  cases  of  wounds  of  the  heart 
is  due  to  pressure  from  effused  blood  in  the  pericardium. 
This  pressure  is  a  cause  to  check  further  haemorrhage.  Op- 
erative procedure   questionable.     Gould  Year  Book,    1896, 

P-  337 
VoiNiTCH,  Sianojeusky  Arch.  Russ  de  Chir.,  St  Petersburg,  1897; 


GUNSHOT,    LACERATED,   AND    INCISED    WOUNDS  II3 

II,  also  Reane  dc  Chir.  Withdrawn  and  recovery  in  four 
weeks.  Paget  Surgery  of  the  Chest.  Ihid,  1897.  Callender 
Needle  Wounds  of  the  Heart.     Paget,  Surgery  of  the  chest, 

1897,  T~Z?>- 
Dr.  Dana  {New  York  Med.  Rec,  Feb.,  1883).     Paget,  Surgery 
of  the  Chest,  1897,  376.    Aspiration  of  air,  emboHsm  of  heart 
through  the  jugular  vein  by  catheter  and  aspiration.     (Senus 
experiments,  1885.)   From  Paget  on  Surgery  of  Chest,  1897,  p. 

377- 
Callender,  on  needle  wound  of  the  heart.     Paget,  Surgery  of 

the  Chest,  1897,  135. 
Bode,  Beitrage  z.  Klin.  Chir.,  1897,  XIX,  167.     In  1896  C.  B. 

Nelson  was  shot.     The  X-Ray  was  used  on  him  in  April,  1896, 

and  under  the  fiuoroscope  the  bullet  could  be  seen  plainly 

moving  in  the  heart  with  each  pulsation  of  the  organ.     Phila. 

Med.  Journal,  1901,  Vol.  7,  No.  17,  p.  797. 
Rehn,  L.,  Ueber  penetrirende  herzwunden  un  herz  naht.     Berlin 

u.  d.  Verhandlg.  d.  Deutsch  /.  Chir.     Leipsic,  XXVI,  56-60. 
Schneider,  G.,  Insuffisance  aortique  consecutive  a  un  trauma- 

tisme  du  coeur.     Med.  Mod.,  Paris,  1897,  VIII,  356. 
Blaisdell,  F.,  Needle  in  the  heart.     Atlantic  Med.  Weekly,  1897, 

VII,  85. 
Bode,  F.,  Versuche  ueber  herzverletzungen.     Beit.  z.  Klin  Chir., 

Tubingen,   1897,  XIX,   167-21 1. 
SoNZALEZ  Alverez,  Aguja  en  el  pericardio.    An.  r.  Acad,  de  Med,, 

Madrid,  1897,  XVII,  297-299. 
Parrozzani,  Penetrating  wound  of  pericardium  and  left  ventricle; 

suture.     Recovery.     Lancet,  London,  1897,  II,  260. 
Booth,  R.  J.,  A  case  of  punctured  wound  of  the  chest  wall  pene- 
trating the  ileum  and  wounding  the  heart.     Brit.  Med.  Jour., 

London,   1897,  II,  469. 
Lennertz,  L.  J.,  Paris,  1897. 
Seemann,  Zur  kasuistik  der  herzverletzungen.     Ztsch.  j.  Med. 

Bemte,  Berlin,  1897,  X,  643. 
Seross  and  Dodds,  Autopsy  in  case  of  stab  wound  of  the  heart. 
Indiana  Med.  Jour.,  1897-98,  XVI,  iii. 


114  THE  SURGERY  OF  THE  HEART 

Prior,  S.,  An  unusual  case  of  wound  of  heart.  Recovery.  Lan- 
cet, London,  1897,  II,  913. 

Nebolyuboff,  v.,  Homicide  in  self  defence  with  perforating 
wound  of  the  heart  through  the  longitudinal  sseptum.  Vestnik 
Ohsh.  hig.  Sudeb  i  Prakt.  Med.,  St.  Petersburg,  1897,  XXXIII, 
No.  63,  Section  100-112. 

Feralli  et  Regnim,  Le  succession!  marbrose  di  una  ferita  pene- 
trante  del  cuore.  Gior.  Med.  d.  r.  esercito,  Roma,  1897,  n.  s., 
XLV,  769-820;  2  pi. 

Ferrareri,  p.,  Ferita  per  arma  de  punta  della  mammari  intima 
di  sinistra  del  pericardio  a  del  cuore  guarigione.  Bull.  d.  Soc. 
Lancisiana  d.  osp.  di  Roma,  1897,  XVIII,  fasc.  i,  312. 

ScHMEY,  F.,  Ein  traumatische  rupture  der  mitralis.  Allg.  Med. 
Centhl.  Ztg.,  Berlin,  1897,  LXVI,  1070. 

Bird,  U.  V.,  Haemorrhage  into  the  pericardium.  Med.  Rec., 
New  York,  1897,  LII,  701. 

Hutchinson,  J.,  Foreign  body  lodged  in  the  heart.  Arch.  Surg., 
London,  1897,  VIII,  386. 

Morgan,  G.,  Needle  in  the  heart,  urgent  symptoms  during  ex- 
traction.    Columh.  Med.  Jour.,  1897,  n.  s.,  II,  592. 

Semeleder,  F.,  Scheilte  wunde  des  herzbeutels  und  das  herzens. 
Tod  durch  bleutung.  Wien.  Med.  Presse,  1897,  XXXVIII, 
1510. 

Garrat,  a.  H.,  Punctured  wound  of  the  heart.  Canada  Med. 
Review,  Toronto,  1897,  VI,  187. 

Spencer  and  Tippett,  Tr.  Clin.  Record,  London,  1896-97,  XXX, 

1-5- 

Seggel,  R.,  Zur  kasuistik  des  schussverletzung  des  scahdels  an 
d.  Stadt.     Allg.  krk.  z.  Mucnch.  (1895),  1897,  IX,  274-313. 

Mendelsohn,  M.,  Ein  fall  von  traumatischer  myocarditis.  Deut. 
Med.  Woch.,  1897,  XXIV,  Ver.  beil,  25. 

Sbozgett,  a.  T.,  Gunshot  wound  of  the  heart.  Brit.  Med.  Jour., 
London,   1898,  I,  86. 

Leonpocher,  Stich  in  das  hcrz.  Tod  noch  drei  tagen.  Fred- 
ericks Bl.  /.  Gerrichtl.  Med.,  Nuremburg,  1897,  XLVIII,  460. 

Fisher,  J.,  Lancet,  London,  1898,  I,  434. 


Plate  XIV. 


A  Non-Penetrating  Transverse  Gunshot  Wound  of 
THE  Left  Ventricular  Wall  Dividing  the  An- 
terior Coronary  Artery  and  Vein. 


(Chapter  on  Wounds  of  Heart.) 


GUNSHOT,    LACERATED,   AND    INCISED    WOUNDS  II 5 

Gluck,  Fall  von    schussvcrlctsung   dcs   herzcns.     Berlin.    Klin. 

Woch.,    1898,  XXXV,   41. 
Hill,  J.  C,  Punctured  wound  of  thorax  involving  the  pericardium 

and  heart.    Death  six  days  after  injury;  necropsy.    Med.Rec, 

New  York,  1898,  LIII,  411. 
OsTAN,  E.,  L'intervention  chirurgicale  dans   les  traumatismes  du 

coeur  et  du  pericarde.     Gaz.  hebd.  de  Med.,  Paris,  1898,  III. 

193-198. 
Tossi,  E.,  L'intercento  chirurgico  nelle  ferite  del  cuore  e  del  per- 

icardio.     Bull.  d.  r.  Acad.  Med.  di  Roma,  1897-98,  XXIII, 

410-413. 
RuDis-JciNSKY,  J.,  Stab  wound  of  the  heart.     Recovery.     New 

York  Med.  Jour.,  1898,  LXVII,  563-566. 
CuRA  (la),  Chirurgica  nei  traumatism  del  pericardio  e  del  cuore. 

Clin.  Chir.,  Milano,  1898,  VI,  170-177. 
Neumann,  A.,  Zur  casuistik  und  behandlung  die  herzbeutel  und 

herzverletzungen.     Deut.  Med.  Woch.,  1898,  XXIV,  Ver-beil, 

90. 
PiCHT,  Stichwunde  des  recten  vorhofes.     Tod  nach  sechs  tagen. 

Ztsch.  j.  Med.,  Beamte,  Berhn,  1898,  XI,  491-493.     Wound 

of  the  heart.     Brit.  Med.  Jour.,  London,  1898,  II,  828. 
Reichard,  V.  M.,  Wound  of  the  heart.     Med.  Rec,  New  York, 

1898,  LXXIII,  535. 
Elsberg,  C.  a.,  Ueber  herwunden  und  herzmaht.     Centbl.    f. 

Chir.,  Leipsic,  1898,  XXV,  1070-1073. 
Behn,  L.,  On  the  suturing  of  penetrating  wound  of  the  heart. 

Ann.  Surg.,  1898,  XXVIII,  669-673. 
Beer,  O.  B.,  Thirty-seven  years  with  a  rifle-ball  in  the  heart. 

Lancet  Clinic,  1898,  n.  s.,  XLI,  496. 
Rydyger,   Ueber  herzwunden.     Wien.  Klin.   Woch.,  1898,  XI, 

1077-1079. 
Graziani,  G.,  Influenza  dello  sforzo  a  del  trauma  sul  cuore.     Ri- 

jorma  Med.,  Palermo,  1898,  XIV,  pt.  4,  518.     The  treatment 

of  wounds  of  the  heart  (Edit.),  Med.  Rec,  New  York,  1899, 

LV,  93- 
AsKANDi,  v.,  Contribuzione  alio  studio  medico-legale  di  alume 


Il6  THE  SURGERY  OF  THE  HEART 

ferite  del  cuore  suppl.  al  policlin.      Roma,  1898-99,  V,  161- 

166. 
Ramoni,  a.,  Duplice  ferita  penetrante  nel  ventricule  destro  del 

cuore;  sutura  guarigune.     Gazz.  Med.  di  Roma,  1899,  XXV, 

1-12. 
Meachem,  J.  G.,  Jour,  of  the  Am.  Med.  Ass^n,  1899,  XII,  178. 
LoisoN,  E.,  Des  blessures  du  pericarde  et  du  coeur  et  de    leur 

traitement.     Rev.  di  Chir.,  Paris,  1899,  XIX,  49-73. 
BuFFNOiR,  Plaie  du  coeur  par  balle  de  revolver,  essai  de  traitement 

chirurgical.     Bull,  et  mem.  Soc.  Anat.,  Paris,  1899,  LXXIV, 

65. 
Lingo,  N.,  Contributo  all'  intervente  chirurgico  nelle  ferite  del 

cuore  e  del  pericardio,  un  cas  di  sutura  del  pericardio  guari- 

gioni  un  caso  di  sutura  dell  cuore  morte,     Gazz.  Internaz.  di 

Med.  Prat.,  Napoli,  1899,  I,  12-26. 
Lingo,  Chirurgie  del  cuore,  un  movo  mezzo  per  obtenere  I'emos- 

tari   temporanea  nelle  ferite  dei  ventricoli.     Gazz.  d.   osp., 

Milano,  1899,  XX,  229-231. 
Reynolds,  John,  Surg.  Hist.  Am.  War  Surg.,  Vol.  I. 
Velpeau,  Stab  wound  left  breast,  diagnosed  heart  pierced;  man 

died  nine  years  later  from  other  causes  and  cicatrix  was  found 

in  pericardium  and  right  auricle.     Traite  d'' Anatomic   Chi- 

rurgicale,  tom.,  I,  p.  602. 
Terrier  and  Raynoud,  Chir.  du  coeur  et  du  pericarde, 
Elsburg,  C.  a..  Jour.  Exper.  Med.,  Vol.  IV,  Nos.  5-6,  pp.  479- 

520,  1899. 
Rose,  Elsberg  Jour.  Exper.  Med.,  Vol,  IV,  Nos.  5-6,  1899,  p. 

484. 
Romberg,  Elsberg  Jour.  Exper.  Med.,  Vol.  IV,  Nos.  5-6,  1899,  p. 

482. 
LoisoN,  Revue  de  Chir.,  1899,  No.  i,  2,  3  et  seq. 
Weber,  Elsberg  Jour.  Exper.  Med.,  Vol.  IV,  Nos.  5-6,  p.  503, 1899. 
HoFMANN,  Elsberg  Jour.  Exper.  Med.,  Vol.  IV,  Nos.  5-6,  p.  503, 

1899. 
Taugl,  Elsberg  Jour.  Exper.  Med.,  Vol.  IV,  Nos.  5-6,  p.  503, 

1899. 


GUNSHOT,    LACERATED,    AND    INCISED   WOUNDS  IT/ 

Hill,  L.  L.,  Heart  wounds,  Med.  Rec,  New  York,  Dec.  15,  1900. 
Several  cases  of  gunshot  wound  of  the  heart  are  reported  in 
which  the  persons  have  walked  various  numbers  of  steps  after 
the  injury.     Proc.  Path.  Soc.  of  Philadelphia. 

Beck,  Numerous  cases  have  been  cited  by  Beck  which  have  not 
been  directly  fatal.     White  and  Stills,  2  ed.,  pp.  329-332,  580. 

Hennen,  Military  Surg.,  p.  x,  464.  Gunshot  wound  of  the  heart. 
System  of  Surg.,  Dennis,  p.  499. 

Jackson,  Mr.,  Rankin's  Abstr.,  of  the  Med.  Sciences,  Vol.,  XXXI, 
p.  165. 

MuLLER,  According  to  Tulpins  (obs.  Md.  Lib.  C-13),  saw  a  case 
of  wound  of  the  right  ventricle  resulting  in  death  nine  days 
later. 

DiEMERBROCECK,  Anat.  Corp.  Ham.,  LVI. 

Bartholin,  Hist.  Anat.  et  Med.  rar.  Vent,  (hist  77).  Injury  left 
ventricle. 

Garmann,  Eph.  Nat.  Car.  obs.  114,  p.  228.  Incised  wound  of 
ventricle. 

Fantoni  (L.  c,  p.  145)  gives  a  case  of  a  soldier  who  died  seventeen 
days  after  a  wound  in  the  left  ventricle. 

Fischer,  Geo.,  Of  Hanover.  Langenbeck,  Arch,  fur  Klin.  Chir., 
B.,  IX,  HH.  S.,  571,  Berlin. 

Rose,  Deutsche  Zeitschr. }.  Chir.,  XX,  329. 

Ollivier  (1.  c.  p.  249)  reports  three  cases  of  stab  wounds  of  the 
left  ventricle  with  empty  and  contracted  heart. 

Heschl,  Coup  de  Path.  Anat.,  p.  176. 

Percy  (Sanson  Obs.  nineteen)  reports  a  case  of  sword  or  knife 
wounds  of  the  heart,  one  hving  nine  hours  after  the  right  auri- 
cle had  been  laid  open. 

Ange,  Case  of  wound  of  the  right  ventricle.  Died  on  the  ninth 
day.  Marrigues  Remarques  sur  les  plaies  du  coeur.  Anc. 
Journal  de  Med.,  t.  XL VIII,  p.  244. 

Ray  (Bonetus  1.  c,  t.,  Ill,  p.  357)  and  Fantoni,  Giorn.  de  di  litter- 
ale  d'ltal.,  t.,  XXI,  p.  148,  each  had  a  case  of  wound  of  the 
right  ventricle  which  died  on  the  twTnty-third  day. 

Koning,  Lehrbuch  de  Chir.,  II. 


Il8  THE  SURGERY  OF  THE  HEART 

CoHNHEiM,  AUgem.  Patholog,  I. 

GoLDEXBERG,  ViTchoiv's  Arcliiv,  C,  III,  88. 

Reedixger,  Krankheiten  des  Thorax.    Deutsche  Chir.,  XLII,  p. 
1 80. 

MoRGAGXi,  De  sed.  et  Caus.  Morborum,  Epist.  69,  Sect.  5. 

W.AiDEYER,  Virchow's  Arch.,  XXXIV,  473. 

RoHERT,  Zingler's  Beitrage  X,  109. 

Bellys,  Sepulcretum  of  Bonetus,  t.,  Ill,  p.  376,  and  Ollivier  (1.  c, 
p.  252)  each  report  cases. 

BoYER,  Foucrays  Med.  eclairee  par  les  Sci.  Phys.,  X.  t.  II,  p.  92, 
reports  wounds  of  Yentricles.     Death  five  days  later. 

DeWitt,  Surger}',  1867. 

Smith,  Stephex,  Operation,  Surger}-,  1887. 

Ollivier,  M.  M.,  axd  Saxsex  Der\^rgie,  Med.  Leg.,Vol.  2,  253, 
Variation  is  supposed  to  be  due  to  the  pecuhar  arrangement 
of  the  muscular  fibres  of  the  heart.  Right  ventricle  most 
frequent  seat  of  injur}-.  The  Due  de  Berri,  who  was  mur- 
dered in  Paris  in  1820,  survived  eight  hours  after  having  re- 
ceived a  wound  in  the  left  ventricle.  "Statistical  obser^'a- 
tions  on  wounds  of  the  heart,  and  on  their  relations  to  Forensic 
Med.,"  with  a  table  of  forty-two  recorded  cases  by  Dr.  Purple; 
also  Am.  Jour.  Med.  Sciences,  July,  1861,  p.  293,  for  a  case  of 
bullet  in  the  wall  of  the  heart  for  twenty  years.  See,  further, 
a  paper,  on  Wounds  of  the  heart,  by  Dr.  Jno.  Redman  Coxe, 
Am.  Jour.  Med.  Sci.,  Aug.,  1829,  p.  307;  and  Archiv.  Gener. 
de  Med.,  Sept.  1839,  for  a  valuable  paper  On  penetrating 
wounds  of  the  heart,  by  M.  Jobert  De  Lomballe,  H. 

Holmes,  Prof.,  of  Montreal  reports  a  case  in  which  the  right  ven- 
tricle of  a  young  man  contained  a  linear  opening,  large  enough 
to  admit  the  finger  without  any  wound  in  the  pericardium, 
leading  to  the  inference  that  the  membrane  had  been  driven 
before  the  ball  and  then  forcibly  distended.  The  ball  was 
found  loose  in  the  chest  cavity.  System  of  Surger)',  Gross, 
1882,  Vol.  II,  p.  381. 

Makixs,  Surgical  experience,  South  Africa,  1900. 

A  CiviLiAX,  War  Hospital,  1901. 


GUNSHOT,    LACERATED,   AND   INCISED   WOUNDS  IIQ 

Madia,  E.,  Ann.  di  med.  nav.,  Roma,  1901,  II,  249. 

Gibson,  Diseases  of  heart  and  aorta,  1901. 

Mauclaire,  Independ.  Med.,  Paris,  1901,  VII,  73. 

Dacosta,    Modern    Surg. 

JocHMANN,  Injuries  of  the  heart  vessels.     Monatsschrift  fur  unjall 

heilkunde,  Leipzig,  Sept.  15,  1902,  p.  277. 
FoucK  AND  Praum,  Deutsche  Medicinishe  Wochenschrift,  June  6, 

1 90 1.     Four  cases  gunshot  wound  not  immediately  fatal  re- 
corded in  Surg.  Hosp.  Am.  War.  Surg.,  Vol.  I,  p.  528, 
Hammond,  L.  J.,  Report  of  gunshot  wound  of  heart.     Annals  of 

Surgery,  Philadelphia,  Pa.,  Oct.,  1902,  p.  550. 
Terrier  and  Reymond,  Surgery  of  the  heart  and  pericardium. 

Gazette  Medicale  de  Paris,  France,  Nov.  i,  1902,  p.  636. 
Gibbon,  J.  H.,  Penetrating  wound  of  the  heart,  Phila.  Med.  Jour., 

Nov.  I,  1902,  p.  636. 
ViGOT,  Plaie  de  coeur.     Annee  med.  de  Caen,  1901,  XXVI,  69-71. 
Madia  E.,  Traumatism!  del  cuore  dal  punto  di  vista  medico- 

legale.     Ann.  di  med,  nav.,  Roma,  1901,  II,  249. 
Mauclaire,  Des  contusions  du  coeur  et  du  pericarde.   Ind.  Med., 

Paris,  1901,  VII,  73. 
Launay,  p.,  Plaie  double  du  coeur  par  balle  (ventricule  gauche) 

sutures  guerison.     Gaz.  d.  hop.,  Paris,  1902,  LXXV,  925-926, 
Manine,  J.,  Un  cas  de  plaie  penetrante  du  coeur  survie  de  34 

heures,  Gaz.  hebdo.  d.  soc.  med.  de  Bordeaux,  1902,  XXIII, 

423-427. 
Hammond,  Levi  J.,  report  of  a  case  of  gunshot  wound  of  the 

thorax  involving  the  heart.     Ann.  0}  Surg.,  Philadelphia, 

1902,  XXXVI,  550-553- 

Wadsworth,  W.  S.,  specimen  showing  bullet  wound  of  heart. 
Proceedings  Philadelphia  County  Medical  Society,  Philadel- 
phia, 1902,  IV,  13-14. 

Hammond,  L.  J.,  report  of  a  case  of  gunshot  wound  of  the  thorax 
involving  the  heart.  Proceedings  Philadelphia  Medical  So- 
ciety, Philadelphia,  1902,  IV,  206-209. 

Mauclaire,  Les  plaies  du  coeur  et  du  pericarde.  Independ.  Med., 
Paris,  1 901,  VII,  9. 


CHAPTER   VI 
CARDIOCLASIA 

Etiology — Rupture  of  the  heart  may  be  due  to  injury 
or  disease  or  both.  Disease  is  conducive  to  traumatic  rupt- 
ure, and  rupture  may  occur  without  trauma  at  any  time  in 
disease.  Fatty  degeneration  is  the  most  frequent  cause  in 
advanced  life,  two-thirds  being  beyond  sixty  years  of  age,  the 
proportion  being  about  the  same  in  each  sex. 

It  may  be  complete  or  incomplete  and  the  opening  of 
any  size,  single  or  multiple,  which  may  or  may  not  com- 
municate with  each  other.  The  fissures  are  usually  parallel 
to  the  muscular  fasciculi,  unless  abscess  be  present,  when 
the  opening  may  be  of  a  perforating  character.  The  edges 
are  irregular  and  materially  aid  in  the  formation  of  clots, 
which  have  frequently  been  found  in  the  opening.  George 
II.  and  the  Princess  of  Brunswick  each  succumbed  to 
rupture  of  the  heart. 

Historical  (i  758-1 903). — Townsend  (1832)  found  in  twen- 
ty-five cases  of  rupture  of  the  heart  that  three  were  of  the 
right  ventricle.  Bayle  found  in  nineteen  cases  that  three 
were  of  the  right  ventricle.  Reports  of  rupture  of  the  va- 
rious chambers  of  the  heart  indicate  that  the  left  ventricular 
wall  is  most  frequently  involved,  spontaneously  or  by  trau- 
matic influence. 

Portal  (1788)  cites  a  death  due  to  spontaneous  rupture 
of  the  left  ventricle.  Matt  (1815)  states  that  the  death  of  a 
young  woman  was  due  to  rupture  of  the  left  ventricle;  veri- 
fied by  autopsy. 

120 


CARDIOCLASIA  121 

This  class  of  rupture  was  recognized  by  Watson  (1828) 
in  a  case  revealed  by  autopsy.  Crass  during  the  same  year 
gives  the  notes  of  two  cases  shown  by  autopsy  to  be  rupture 
of  the  left  ventricle,  as  does  Adams  (1828)  also. 

It  would  appear  from  Smith's  (1836)  case  that  fatty  de- 
generation plays  an  important  role  as  a  factor  in  producing 
such  a  lesion.  In  his  case  of  rupture  of  the  left  ventricle 
there  was  not  only  fatty  degeneration  of  the  heart,  but  free 
oil  was  abundant  in  the  blood. 

Bodington  (1843),  Walshe  (1844),  Crisp  (1846),  Quain 
(1846),  Fletcher  (1847),  Amry  (1848),  Coulson  (1848),  Ben- 
berg  (1850),  and  O'Conner  (1850),  each  report  interesting 
cases  of  rupture  of  the  left  ventricle.  The  last-named  gentle- 
man found  rupture  of  the  pericardium  in  addition  to  rupt- 
ure of  the  ventricular  wall.  This,  no  doubt,  was  due  to 
trauma. 

Quain,  White,  and  Hill  each  report  a  case  of  rupture  of 
the  left  ventricle,  the  cause  in  each  being  attributed  to  aneu- 
rysm of  the  ventricle. 

Godden  (1854),  Fuinell  (1857),  Popham  (1857),  Coote 
(1861),  Wilks  (1864),  Ramskill  (1866),  Meyer  (1871),  and 
Thomas  (1883)  each  report  a  case  of  rupture  of  the  left  ven- 
tricle. The  case  of  Meyer  terminated  in  recovery.  This  is 
indeed  a  unique  case  and  one  from  which  many  important 
deductions  may  be  drawn. 

Blauvelt  (1883)  reports  a  case  in  which  both  ventricles 
were  ruptured.  In  the  case  of  Eraser  (1897)  the  rent  in  the 
left  ventricular  wall  was  quite  extensive.  Thus  it  is  shown 
that  many  varieties  of  rupture  of  the  left  ventricular  wall 
may  take  place  spontaneously  and  that  fatty  degeneration  is 
probably  the  causative  factor.  Konskoff  states  that  rupture 
of  any  of  the  heart  fibres  is  rare,  and  that  he  found  but  three 
cases  in  8,000  autopsies. 

Rupture  of  the  right  ventricle  spontaneously  or  from 
trauma  is  very  rare,  as  shown  by  the  few  recorded  cases, 


122  THE  SURGERY  OF  THE  HEART 

among  the  first  of  which  are  those  of  Ashburner,  in  which 
both  ventricular  walls  were  ruptured  spontaneously.  Chalice 
(1843),  Learning  (1844),  Johnson  (1851),  Davis  (1859),  Duka 
{1862),  Fennell  (1869),  and  Prudden  (1888)  each  report  a 
case  of  spontaneous  rupture  of  the  right  ventricular  wall. 
In  the  case  of  Prudden  the  rupture  was  the  result  of  general 
fatty  degeneration  from  atheroma  of  the  coronary  arteries. 

Squire  (1891)  reports  a  case  of  rupture  of  the  right  ven- 
tricle with  death  at  end  of  twenty-five  hours,  revealed 
by  autopsy.  Green  (1894)  reports  a  case  of  thrombosis  and 
rupture  of  the  right  ventricle  in  a  child  nine  and  one-half 
months  old.  Hunter  (1897)  reports  a  death  from  an  incom- 
plete rupture  of  the  right  ventricle  with  adherent  pericar- 
dium. Thomas  (1825),  Rutherford  (1828),  Thomas  (1830), 
Lankaster  (1849),  and  Hall  (1852),  each  report  a  case  of 
spontaneous  rupture  of  the  rigJif  auricular  zvall.  In  the  case 
of  Hall  there  was  an  aneurysmal  cavity  in  the  substance  of 
the  ventricular  sceptum  of  the  heart.  The  rupture  in  the  right 
auricle  was  sudden  and  fatal. 

Hudson  (1859)  mentions  a  case  of  rupture  of  the  right 
auricle  during  labor.  Cregen  (1859),  Finnell  (1869),  and 
Shearer  (1872),  each  report  a  case  of  such  a  rupture.  The 
case  of  Finnell  is  especially  interesting  in  that  autopsy  re- 
vealed a  small  saccular  aneurysm  of  the  ascending  aorta  with 
hypertrophy  and^fatty  degeneration  of  the  heart. 

Armory  (1873)  found  by  autopsy  that  compression  of 
the  thorax  had  ruptured  the  right  auricular  wall.  Tennison 
(1879),  Duffy  (1881).  and  Thompson  (1884),  each  record  a 
case  of  rupture  of  the  right  auricle.  Vase  (1849),  Clapton 
(1870),  and  Johnson  (1877),  each  report  a  case  of  rupture  of 
the  left  auricular  zcall.  There  was  an  aneurysm  of  the  ascend- 
ing aorta  in  the  case  of  Johnson. 

Allen  (1880)  reports  rupture  of  the  left  auricular  ap- 
pendage of  the  heart.  Mackintosh  (1890)  reports  a  case  of 
spontaneous  rupture  of  the  left  auricle. 


CARDIOCLASIA  1 23 

Rupture  of  one  or  all  of  the  cardiac  walls  from  violence  may 
occur  at  any  age,  and  there  are  fewer  cases  reported  than 
those  of  spontaneous  rupture.  Gariel  (1835),  Salkice  (1839), 
and  Geoghegan  (1839),  each  report  heart  rupture  due  to 
violence.  Fenner  (1846)  mentions  a  case  of  rupture  of  the 
heart  with  a  compound  fracture  of  the  thigh  in  which  the 
patient  survived  twenty-eight  and  a  half  hours.  In  the  case 
of  Carter  (1847)  it  was  the  interventricular  saeptum  of  the 
heart  that  was  ruptured  by  violence.  This  was  so  in  the  case 
of  Beith,  except  that  in  addition  the  rent  extended  through 
the  walls  of  the  right  ventricle.  In  the  case  of  Stanley  the 
rupture  involved  both  auricular  walls. 

Leared  (1852)  mentions  a  similar  case,  while  Hewitt  re- 
cords a  case  of  traumatic  rupture  of  the  ventricular  saeptum 
of  the  heart  without  any  laceration  of  the  pericardium.  Ward 
(1862),  in  reporting  a  case  of  heart  rupture  by  external  vio- 
lence, states  that  it  was  without  break  of  the  skin. 

Both  Ellis  and  Oyler,  during  the  year  1863,  report  cases 
of  traumatic  rupture  in  fatty  degeneration  of  the  heart  with- 
out external  manifestations.  In  the  case  of  Oyler  the  lacera- 
tion occurred  in  the  wall  of  the  left  auricle,  which  contained 
fibrous  concretions  undergoing  softening  in  the  same  auricle. 
Mackenzie  (1866)  reports  a  case  of  rupture  of  the  heart  in 
a  child,  complicated  with  fracture  of  several  ribs.  This  class 
of  rupture  is  well  established. 

The  aorta  may  rupture  independently,  or  it  may  be  asso- 
ciated with  rupture  of  any  one  or  all  of  the  cavities  of  the  heart 
traumatically  or  idiopathically.  Curling  (1838)  reported  a 
case  of  rupture  of  the  heart  and  aorta.  Davy  (1839)  gave 
notice  of  a  fatal  case  of  rupture  of  the  heart  and  aorta, 
with  an  account  of  some  experiments  on  the  power  of  re- 
sistance of  the  heart  and  great  vessels.  Hewitt  (1846) 
gave  cases  of  rupture  of  the  heart  and  large  vessels  re- 
sulting from  injury.  Lewis  (1883)  reports  a  case  of  rupture 
of  the  aortic  valves  during  severe  muscular  strain.     Biggo 


124  THE  SURGERY  OF  THE  HEART 

(1890)  reports  a  similar  case,  due  to  a  fall.  Hektoen  (1892) 
reports  such  an  injury  with  aneurysm  of  the  right  auricular 
appendix.  Rolleston  (1890)  reports  a  rupture  of  the  aortic 
arch  in  connection  with  heart  rupture,  while  Baylac  reports 
rupture  of  the  aortic  arch.  Williams  (1896)  records  a  case 
of  rupture  of  the  cardiac  vessels.  Eshner  (1900)  reports  a 
case  of  rupture  of  an  aortic  leaflet  in  a  case  of  right  hemi- 
plegia W'ith  aphasia  due  to  cerebral  haemorrhage. 

Rupture  of  the  coronary  arteries  may  he  due  to  injury  or 
disease  and  may  involve  any  part  of  one  or  more  vessels. 
Lally  (1862)  reports  a  case  of  rupture  of  the  coronary 
artery  wath  obscure  symptoms  and  death,  and  Cutler 
(1880)  reports  a  case  of  embolism  of  the  coronary  artery 
with  rupture  of  the  heart.  Josiasis  and  Betremeux  (1884) 
report  a  case  of  atheroma  of  the  coronary  arteries.  Steven 
(1884)  reports  a  case  of  fatty  degeneration  and  disease  of 
the  coronary  arteries  with  cardiac  rupture.  Saivin  (1887) 
reports  a  case  of  thrombosis  of  the  coronary  artery  with  rupt- 
ure of  the  heart.  Armand  (1889)  reported  spontaneous  oblit- 
eration of  the  coronary  artery  in  a  case  of  Hodgkin's  disease. 
Milan  (1897)  reports  thrombosis  of  the  coronary  artery  with 
cardiac  rupture. 

Sherman  (1871)  cites  a  case  of  cardiac  rupture  due  to 
violence.  In  the  case  of  Shearer  (1874)  the  patient  died 
at  the  end  of  eight  hours.  Clayborn  (1874),  Whar- 
ton (1874),  Hielt  (1875),  Packard  (1877),  Deheune  (1878), 
and  Finnell  (1880)  each  report  traumatic  cardiac  rupt- 
ure, the  case  of  Finnell  being  due  to  indirect  violence. 
Hanford  (1880)  reports  a  rupture  from  external  violence 
without  perforating  wounds.  Draper  (1879)  mentions  a  case 
of  rupture  of  the  interventricular  saeptum  of  the  heart  in  con- 
sequence of  external  violence.  Bennett  (1890)  records  a  case 
of  cardiac  rupture  complicated  with  fracture  of  the  sternum 
and  costal  cartilages.  O'Brien  (1893)  reports  a  similar  case. 
Nibling   (1896)   writes  on   a   case  of  heart   rupture  due  to 


Plate  XV. 


Section    of    Heart    Muscle    Showing     Syphilitic 

Lesion. 


(Chapter  on  Syphilis.) 


CARDIOCLASIA  125 

trauma,  as  does  Bennett  (1896)  also,  while  Gibbons  (1897) 
speaks  of  a  case  due  to  a  blow  by  a  stick,  with  survival  for 
three  hours.  Oscar  and  Voelker  during  the  same  year  report 
rupture  of  the  ventricular  saeptum.  Ghedini  (1897)  also  re- 
ports such  a  case.  Newton  (1899)  mentions  a  case  of  a 
man  twenty  years  old  who  was  thrown  upon  a  bicycle  handle, 
fracturing  and  pushing  the  sixth  costal  cartilage  into  the  apex 
of  the  right  ventricle. 

Among  other  causes  of  heart  rupture  is  tetanus,  cases 
of  this  character  having  been  reported  by  Ferguson  (1883) 
and  Duclaux  (1878).  There  was  one  in  a  case  of  arsenical 
poisoning  (?)  reported  by  Lewis  and  Adams  (1887)  and  one 
by  Glikman  (1893)  during  the  act  of  defsecation,  and  one  due 
to  cold  bathing. 

Several  cases  of  heart  rupture  have  been  reported  as  hav- 
ing occurred  in  the  insane  during  violent  periods.  Among 
them  are  those  of  Mickle  (1883),  Pichenot  (1888  and  1889), 
also  Nash  (1892)  and  Beadles  (1892). 

Rutchinski  reports  a  spontaneous  rupture  of  the  heart. 
Hamilton  (1903)  records  eight  cases  of  heart  rupture  in  in- 
sane subjects,  six  in  the  left  ventricular  wall,  one  in  the  right 
ventricular  wall,  and  one  in  the  right  auricular  wall.  There 
were  two  openings  in  the  right  ventricular  wall. 

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I30  THE    SURGERY   OF    THE    HEART 

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CARDIOCLASIA  I3I 

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132  THE  SURGERY  OF  THE  HEART 

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CARDIOCLASIA  I 33 

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134  THE  SURGERY  OF  THE  HEART 

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Plate   XVI. 


X  235. 


1  •'•.>••'  .-^ 


X  2;j(). 

FlBROMx\TA. 


(Chapter  on  Benign  Tumors.' 


CARDIOCLASIA  135 

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p.  381. 


136  THE  SURGERY  OF  THE  HEART 

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Draxguel,  Rupture  du  coeur.     Bull,  de  la  Soc.  anat.  de  Nantes, 

1881,  Paris,  V,  1882,  9. 
Baldwin,  Specimen  of  Ruptured  Heart.    Lancet,  London,  1883, 

II,  1093. 
Ferguson.  F.,  Rupture  of  the  Heart.    Med.  Rec,  New  York, 

XXIV,  1883,  584. 
Blal'\'ELT,  H.  C,  New  York  Med.  Times,  XI,  1883-84,  14. 
JosL\s,  Rupture  spontanee  du  coeur,  etc.  Bull,  de  la  Soc.  anat.  de 

Paris,  III,  1883,  LV,  237-241. 
Loving,  Starling,   1883,  reported  to   the   Central   Ohio  Med. 

Soc'y  a  case  of  rupture  of  the  heart  in  a  Railroad  Conductor 

as  he  attempted  to  pull  himself  upon  the  coach  step. 
Levis,  M.  J.,  Phila.  Med.  Times,  XIV,  1883-84,  583. 
Dunn,  T.  D.,  Rupture  of  the  Heart.     Med.  and  Surg.  Reporter, 

Philadelphia,  LI,  1884,  289. 
Green,  A.  W.,  Two  Cases  of  Rupture  of  the  Heart.     Lancet,  Lon- 
don, 1884,  II,  317. 
Josias  Betrexieux,  Rupture  spontanee  du  coeur;  degenerescence 

graisseuse  du  coeur;  atherome;  caillot  ancien  de  I'artere  coro- 

naire   anterieure;   cirrhose  cardiaque;   nephrite   interstitielle. 

Prog,  med.,  Paris,  XII,  1884,  48. 
Ross  ANT)  Merchent,  Two  Cases  of  Rupture  of  the  Heart.     Tr. 

of  the  Med.  Soc.  of  the  State  of  New  York,  1884,  233-237. 
Baldwtn,  Ruptured  Heart.     Brit.  Med.  Jour.,  1884,  I,  12. 
Pilgrim,  C.  W.,  A  Case  of  Spontaneous  Rupture  of  the  Heart. 

Am.  Jour.  0}  Insanity,  XLI,  1884-85,  305-308. 
Tompkins,  H.  H.,  Spontaneous  Rupture  of  the  Heart.     Brit.  Med. 

Jour.,  London,  1885,  I,  891. 
Gron,  K.,  Tilfaelde  of  skerose  of  arteria  coronaris  cordis.     Med. 

Konsekuti  myocardit  pludselig.   Dod.  Norsk.  Mag.  }.  Laegevi- 

densk,  Christiania,  XV,  II,  1885,  1827. 


CARDIOCLASIA  1 37 

Hadden,  W.  B.,  Two  Cases  of  Rupture  of  the  Heart.  Brit.  Med. 
Jour.,  London,  1883,  II,  291;  Rupture  of  the  Heart;  Acute 
Rheumatic  Pericarditis  and  Fatty  Degeneration.  Rep.  of 
the    Sup.  Surg.  Gen.,  U.  S.   M.  H.  S.,  Washington,   1883, 

234- 

MiCKLE,  A.  F.,  Cases  of  Spontaneous  Rupture  of  the  Heart  in  the 
Insane.     Edlnh.  Med.  Jour.,  XXIX,  1883-84,  710-713. 

Wyckoff,  C.  C,  Rupture  of  the  Heart.  Bufj.  Med.  Jour.,  XXIII, 
1883-84,  297,  299. 

Mackenzie,  J.  A.,  Rupture  of  the  Heart.  Brit.  Med.  Jour.,  Lon- 
don, 1884,  I,  3091. 

Dunn,  T.  D.,  Rupture  of  the  Heart.  Med.  and  Surgical  Rep., 
LI,  1884,  289. 

Green,  A,  W.,  Two  Cases  of  Rupture  of  the  Heart.  Lancet, 
London,  1884,  II,  217. 

Merchent,  R.  L.,  Two  Cases  of  Rupture  of  the  Heart.  Trans, 
of  the  Med.  Soc.  of  the  State  of  New  York,  1884,  233-237. 

Champiel,  Mort  subite  par  rupture  du  coeur.  Prog,  med.,  Paris, 
XII,    1884,    1041. 

Leveque,  E.,  Rupture  spontanee  et  incomplete  du  coeur.  Exam, 
histologique  par  M.  Branet.  Bull,  de  la  Soc.  anat.  de  Paris, 
LIX,    1884,    416-418. 

Peever,  H.  G.,  Case  of  Rupture  of  the  Heart.  Ind.  Med.  Jour., 
HI,  1884,  565- 

Steven,  J.  L.,  Cases  of  Spontaneous  Rupture  of  the  Heart  and 
Remarks  on  Pathology  of  the  Condition,  with  Special  Refer- 
ence to  Fatty  Degeneration  and  Diseases  of  the  Coronary 
Arteries.     Glasgow  Med.  Jour.,  XXII,  1884,  413-427. 

FuSHER,  T.,  Case  of  Rupture  of  Right  Ventricle  of  the  Heart. 
Tr.  of  the  Path.  Soc,  London,  XXXI,  1879-80,  72;  i  pi.;  also 
Med.  Times  and  Gaz.,  London,  1880,  I,  23;  also  abstr.,  Brit. 
Med.  Jour.,  London,  1880,  I,  14. 

Thompson,  G.,  Case  of  Rupture  of  Right  Auricle  of  the  Heart. 
Bristol  Med.  and  Surg.  Jour.,  II,  1884,  48-50. 

Purple  reported  two  cases  that  did  not  prove  immediately  fatal. 
New  York  Med.  Jour.,  May,  1885. 


138  THE  SURGERY  OF  THE  HEART 

Hardy,  H.  N.,  A  Case  of  Rupture  of  the  Heart.     Brit.  Med.  Jour., 

London,  1885,  I,  891. 
Pelgrim,  C.  W.,  a  Case  of  Spontaneous  Rupture  of  the  Heart. 

Am.  Jour,  oj Insanity,  XLI,  1884-85,  305-8. 
Mattei,  R.,  Di  una  doppia  rottura  del  cuore  per  lipomatosi  in- 

terstiziale  del  miocardio.     Boll,  delta  Soc.  tra  i  cult,  delta  Soc. 

med.  in  Siena,  III,  1885,  186-189. 
Fereol,  Retrecissement  et  thrombose  de  I'artere  cardiaque  gauche; 

rupture  de  cet  organe.     Gaz.  des  hop.,  Paris,  XLIH,  1887,  134. 
Plastwich,  De  rupture  cordis  spontanea.     Regimonti  Pr. 
Panum,  O.  L.,  The  Case  of  the  late  Prof.  Panum,  by  Finer,  trans- 
lated by  H.  Mygina.     New  York  Med.  Jour.,  XLH,  1885,  619. 
Robin,  A.,  Sur  les  ruptures  du  coeur.  Bull,  et  mem.  de  la  Soc, 

med.  des  hop.  de  Paris,  II,  1885,  401-406. 
Davega,  T.,  Goutte  chronique;  rupture  du  cceur;  mort  rapide. 

Jour,  de  med.  de  Bordeaux,  XV,  1885-86,  286. 
Mecondrew,  H.,  a  case  of  Rupture  of  the  Heart.     Brit.  Med. 

Jour.,  London,  1886,  I,  297. 
Trier,  Ein  Fall  von  Rupture  des  Herzens.     Arch,  fur  klin.  Med., 

VII,  1886,  657-661. 
Grant,  O.,  Rupture  of  the  Heart.     Brit.  Med.  Jour.,  London,  1886 

I,  928. 
Beck,  H.,  Zur  Kenntniss   der   Entstehung  der  Herzrupture  und 

des  chemischen  partiellen  Herzaneurysma.    Tubingen,  1886. 
Von  Limbeck,  R.,  Zur  Casuisytik  der  Herzruptur.     Prag.  med. 

Woch.,  1886,  XI,  403. 
McKeough,  Rupture  of    the  Heart.      Canada  Med.  and  Surg. 

Jour.,  Montreal,  XV,  1886-87,  369. 
Foot,  A.  W.,  Spontaneous  Rupture  of  the  Heart.     Tr.  of  the  Acad. 

of  Med.  in  Ireland,  IV,  1886,  335. 
Lewis  and  Adams,  Weekly  Med.  Review,  St.  Louis,  XV,  1887,  144. 
Saivin,  Bost.  Med.  and  Surg.  Jour.,  CXVII,  1887,  37. 
Friberger,  R.,  Fall  of  hjcrruptur  mod  bristning  of  pericardium 

ups  ala  lakaref.     Forh.,  1886-67,  XXII,  439-442. 
Holmes,  J.  C,  Rupture  of  the  Heart.     Med.  and  Surg.  Reporter, 

LVII,  1887,  479. 


i 


CARDIOCLASIA  139 

Neelson,  F.,  Uebcr  spontanc  Ruptur  des  Hcrzcns  durch  Vcr- 
schluss  der  Coronarterie  und  hammorrhagischcn  Infarctc  dcs 
Herzmuskels  ncbst  Bemerkungen  iibcr  die  Genese  Ham- 
morrhagischer  Infarcte.    Beit.  z.  path.  anat.  u.  Klin.,  Leipsic, 

1887,  113-133- 

Meilhon  Megelomane,  Mort  subite  par  rupture  du  coeur.  Ann. 
med.  psych.     Paris,  VI,  1888,  236-244. 

Reddy,  H.  L.,  Rupture  of  the  Heart.  Canada  Med.  Record,  Mon- 
treal, XVI,  1887-88,  100. 

Galassi,  G.,  Contributo  alia  casuistica  della  cardioresi  spontanee. 
Boll,  della  Soc.  lancisiana  degli  osp.  di  Roma,  VII,  1887, 

54-57- 
Hun,  H.,  Traumatic  Rupture  of  the  Valves  of  the  Heart,     Albany 

Med.  Ann.,  IX,  1888,  161-163. 

MuER,  J.  S.,  A  Case  of  Spontaneous  Rupture  of  the  Heart;  Ne- 
cropsy.    Glasgow  Med.  Jour.,  XXIX,  1888,  378-384. 

Prudden,  T.  M.,  Proc.  of  the  New  York  Path.  Soc,  1888,  195. 

Meyer,  G.,  Zur  Kenntniss  der  spontanen  Herzruptur.  Deutsch. 
Arch.  }ur  klin.  Med.,  XLIII,  1888,  379-408. 

Roche,  Ruptures  spontan^es  du  cceur.  Bull,  de  la  Soc.  med.  de 
Lyon,  1887,  Auxerre,  XXVIII,  1888,  97-105. 

Agnew,  Surgery,  Vol.  I,  1889,  422-423. 

Gamgee  has  reported  twenty-eight  cases  of  rupture  of  the  heart 
by  external  force.  Right  and  left  side  equally  affected.  Ag- 
new's  Surgery,  Vol.  I,  1889,  423. 

Tezjokoff,  N.  I.,  Case  of  Spontaneous  Rupture  of  the  Heart. 
Med.  Obozr.,  Mosk.,  XXXII,  1889,  104. 

GuLLEMANT,  JuLES,  J.  B.  L.  M.,  Consideration  sur  quelques  ob- 
servations de  rupture  spontanee  du  cceur.     Bordeaux,    1889 

Crocker,  J.  H.,  Case  of  Rupture  of  the  Left  Ventricle  of  the  Heart. 
Lancet,  London,  1890,  I,  17. 

Biggs,  H.  M.,  New  York  Med.  Jour.,  LI,  1890,  76. 

Armaud,  F.,  Marseille  med.,  XXVI,  1889,  703-710. 

Mackintosh,  M.,  Lancet,  London,  1890, 1,  239. 

White,  W.  H.,  Unusual  Form  of  Rupture  of  the  Heart.  Tr.  of 
the  Path.  Soc.  of  London,  XL,  1888-89,  58. 


I40  THE  SURGERY  OF  THE  HEART 

Mallet,  H.,  Rupture  spontanee  du  coeur.     Bull,  de  la  Soc.  anat. 

de  Paris,  LXIV,  1889,  400-405. 
PiLLiET,  Rupture  du  coeur.     Ihld,  478. 
Mackenzie,  S.  C,  Simple  and  Complicated  Rupture  of  the  Heart. 

Indian  Med.  Gaz.,  Calcutta,  XXV,  1890,  105. 
PiNCHENOT,  Bull,  de  la  Soc.  de  Med.  de  Lyon,  1889,  Auxerre,  1890, 

XXX,  69-75. 
Hebb,  R.  G.,  Rupture  of  the  Heart.     Tr.  of  the  Path.  Soc.  of  Lon- 
don, XLI,  1889-90,  41. 
Bennett,  E.  H.,  Tr.  of  the  Royal  Acad,  of  Med.  in  Ireland,  VHI, 

1890,  392-394. 
Squire,  C.  L.,  Med.  Rec,  New  York,  XXXIX,  1891,  621. 
Tretzel,  L.,  Ruptur  einer  Aortenklapper  in  Folge  korphcher  An- 

strengung.     Berl.  klin  Woch.,  XXVIII,  1891,  1073. 
Karplus,  R.,  Ein  Fall  von  penetrirender  Herzwunde  mit  Embolic 

des  Gehirns.     Wien  klin  Woch.,  IV,  1891,  699-702. 
Richards,  J.  P.,  A  Case  of  Fatal  Injury  to  the  Pericardium  and 

Heart;  Necropsy.     Lancet,  London,  1891, 1,  11 51. 
Bruce,  J.,  Case  of  Rupture  of  the  Left  Ventricle  of  the  Heart. 

Jour.  0}  Ment.  Science,  London,  XXXVIII,  1892,  85. 
Nash,  V.,  Jour,  of  Ment.  Science,  London,  XXXVIII,  1892. 
Rouse,  E.  R.,  Case  of  Ruptured  Heart.     Lancet,  London,  1892, 

I,  310. 
Hektoen,  L.,  N.  Am.  Pract.,  IV,  1892,  157-163. 
MuDD,  B.  W.,  Ruptured  Heart.     Lancet,  London,  1892,  I,  578. 
RoLLESTON,  H.  D.,  Tr.  of  the  Path.  Soc.  of  London,  XLII,  1890- 

91.  57- 
Hern,  Max.,  Ueber  einen  Fall  von  Spontane  Herzruptur.    Kon- 

igsburg,  1892. 
Merklen,  p.,  Mort  subite  par  rupture  du  coeur  sans  epanchement 

de  sang  dans  le  pericarde.     Bull,  et  mem.  de  la  Soc.  des  hop.  de 

Paris,  LX,  1892,  813-818. 
Glasson,  O.  J.,  Death  from  Rupture  of  the  Right  Ventricle  of  the 

Heart.     Med.  Times  and  Hospital  Gaz.,  London,  XXI,  1893, 

173- 
Glikman,  Z.,  Russk.  Med.,  St.  Petersburg,  XVIII,  1893,  10.  3 


CARDIOCLASIA  I4I 

O'Brien,  C.  M.,  Med.  Press  and  Circ,  London,  LVI,  1893,  353. 
Coats,  J.,  Rupture  of  the  Heart.     Tr.  of  the  Glasgow  Path,  and 

Chn.  Soc,  IV,  1891-93,  43. 
Deane,  C.  M.,  a  Case  of  Rupture  of  the  Heart.     Australas.  Med. 

Jour.,  XV,  1893,  471. 
Kakorski,   K.,   Spontaneous  Rupture  of  the  Heart.     Bolnitsch 

Gaz.  Botkina,  St.  Petersburg,  IV,  1893,  1143-1150. 
Beadles,  C.  F.,  Tr.  of  the  Path.  Soc.  of  London,  XLIV,  1892,  18- 

23- 
Webersberger,   Ein  Fall  von  Herzruptur.     Deutschmil.,  arzil. 

Ztschr.,  Berlin,  XXIII,  1894,  305-310. 
Gaevert,  C,  Un  cas  de  rupture  spontanee  du  coeur.     Flandre  med. 

II,  1895,  641-645. 
Guillemont,  L.,  Rupture  du  coeur.     Ibid.,  599-561. 
Jay,  Rupture  du  coeur.     Bull,  de  la  Soc.  anat.  de  Paris,  LXX,  1895, 

497- 
Ramond,  F.,  Dislocation  segmentaire  du  myocarde  dans  un  cas  de 

coeur  force.     Bull,  et  mem.  de  la  Soc.  med.  des  hop.  de  Paris, 

XII,  1895,  796-799- 

Robin  et  Nicolle,  De  la  rupture  du  coeur.     Paris,  1895. 

Baylac,  J.,  Arch.  med.  de  Toulouse,  1895,  94-118. 

CoLLiNGS,  D.  W.,  A  Case  of  Thrombosis  and  Rupture  of  the  Heart 
in  an  Infant.     Brit.  Med.  Jour.,  London,  1895, 1,  1202. 

Penneato,  p.,  Rottura  del  cuore.  Rev.  veneta  di  sci.  med.  Vene- 
zia,  XXI,  1894,  506,  508. 

QuAiN,  R.,  Fatty  Degeneration  of  the  Heart  Causing  Death  by 
Rupture  of  the  Left  Ventricle.  Tr.  of  the  Path.  Soc.  of  Lon- 
don, III,  269-271. 

Sanduine  reports  a  case  opening  in  the  base  of  an  ulcer  in  the 
heart  (left  ventricle).  Quart  of  blood  in  the  pericardium. 
Presse  med..  No.  15,  91. 

Green,  Am.  Jour.  0}  the  Med.  Sci.,  Dec,  1894. 

Embley,  Rupture  in  an  Aneurysmal  Dilatation  of  the  Left  Ven- 
tricle.    Australian  Med.  Jour.,  x\ugust  20,  1895. 

COLLINGS  reports  a  case  of  spontaneous  rupture  of  the  heart  in 
a  man  aged  fifty-three  years.     Lancet,  April  20,  1895. 


142  THE  SURGERY  OF  THE  HEART 

Kauskoff,  Presse  med.,  March,  1896. 

Peron,  a.,  Rupture  spontanee  du  coeur.     Bull,  de  la  Soc.  anat. 

de  Paris,  LXX,  1895,  197. 
Rankin,   G.,  Rupture  of  the  Heart.     Birmingham  Med.  Rev., 

XXXVIII,  1895,  I  ic^i  15. 
Shiperovich,  M.  v.,  On  Spontaneous  Rupture  of  the  He;, it.     Bol- 

nitsch  Gaz.  Botklna,  St.  Petersburg,  VI,  1895,  681-71 1. 
Stoent:scu,  N.,  Morte  subite  un  irma  rupturei  spontanee  a  cardului 

stang.     Spitalul,  Bucurasci,  XV,   1895,  64-67. 
Tarxier,  J.  A.,  A  Case  of  Spontaneous  Perforation  of  the  Heart 

with   Obscure   Sjnnptoms.     Boston  Med.   and  Surg.   Jour., 

CXXXIII,   1895,  62-66. 
Williams,  H.  U.,  Rupture  of  the  Left  Ventricle.     A  Study  of  a 

Case.     Med.  Rec,  New  York,  XL VII,  1895,  618. 
NiBLiNG,  A.,  Friederichs  Bl.  /.  Gerichtl.  Med.,  Nuremberg,  1896, 

XLVII,  93-102. 
Samgin,   v.,    Rupture   of   the   Heart   due   to  Rheumatic  Ulcer- 
ative   Endocarditis.      Med.    Obozr.,    Mosk.,    XLV,    1896, 

Bartikovski,  Ein  Fall  von  auscheinender  Neuritis  und  tod  durch 

Herzruptur.     Aertzl.  sachverst.  Ztg. 
Kelynack,  T.  N.,  On  Spontaneous  Rupture  of  the  Heart.     Lan- 
cet, London,  1896,  II,  165. 
Pcholin,  On  Spontaneous  Rupture  of  the  Heart  Muscle.     Voy- 

enne-Med.  Jour.,  St.  Petersburg,  CLXXXVI,  1896,  i  Sect. 

200-207. 
Nebolyuboff,  V.  P.,  Rupture  of  the  Heart  due  to  a  Fall  from  a 

Height.     Dnevnik.    Obsh.    Vrach.    Pri.    Imp.  Kazan.  Univ. 

(1895)  1896,  41-44- 
Simpson,  F.  S.,  Case  of  Rupture  of  the  Heart.     Brit.  Med.  Jour., 

London,   II,    1896,   654. 
Cole,  G.,  Fatty  Degeneration  and  Rupture  of  the  Heart.     New 

Albany  Medical  Herald,  XVI,  1896,  295-297. 
Williams,  J.  W.,  Lancet,  London,  1896,  II,  1678. 
Robertson,  C,  Note  on  a  case  of  Rupture.     Lancet,  London, 

1897,  I,  240. 


Pl-AIE    XVU. 


X  200. 

Fibroid. 


X  so. 
Lipoma. 


(Chapter  on  Benign  Tumors.) 


CARDIOCLASIA  I43 

Bennet,  E.  H.,  Trans,  of  the  Roy.  Acad,  of  Medicine  in  Ireland, 

XIV,  1896,  303-306. 

Cantieri,  a.,  Delia  roltura  delle  valvule  cardiachc  in  seguito  a 
sferzo  violente  od  a  trauma.     Clin,  med.,  Pisa,  III,  1897,  19, 

34,  47- 
Fraser,  J.  A.,  Brit.  Med.  Jour.,  London,  1897,  I,  783. 
Groom,  W.,  A  Case  of  Rupture  of  the  Heart.     Lancet,  London, 

1897,  I,  1202. 

Kaufmann,  E.,  Herz  einer  68  jahrigen  arbeitarwitere  mit  innerer 

Rupture.     Allg.  Med.  Ztg.,  Berlin,  LXVI,  1897,  517. 
MiLiAN,  G.,  Bull,  de  la  Soc.  anat.  de  Paris,  LXXII,  1897,  436- 

438. 

Brady,  E.  T.,  Case  of  Rupture  of  the  Heart.  Virginia  Med.  Semi- 
monthly, Richmond,  II,  1897-98,  233. 

Shelby,  C.  P.,  Jr.,  Rupture  of  the  Heart.  Med.  Rec.,  New  York, 
LII,  1897,  319. 

Brayton,  a.  W.,  a  Case  of  Rupture  of  the  Heart.  Ind.  Med. 
Jour.,  XVI,  1897-98,  208. 

Hunter,  D.,  Lancet,  London,  1897,  II,  1583. 

Gibbons,  J.  B.,  Indian  Med.  Gaz.,  Calcutta,  XXXII,  1897,  443- 

445- 
Farnarier,  F-,  Un  cas  de  rupture  du  coeur  droit.     Marseille  med., 

XXXV,  1898,  136-140. 
Fox,  R.  H.,  Rupture  of  the  Heart,  Non-perforating.     Tr.  of  the 

Path.  Soc.  of  London,  XLVIII,  1896-97,  49-51. 
DuPLAUT,  Berlin  klin.  Woch.,  Dec.  5,  1898,  Reports  a  case  of  rupt- 
ure with  death  six  days  later,  due  to  breaking  down  of  an 

ol'd  infarct. 
Greig,  W.  J.,  Spontaneous  Rupture  of  a  Fatty  Heart.     Can.  Pract., 

Toronto,  XXIII,  1898,  80. 
Oscar  and  Voelker,  Tr.  of  the  Path.  Soc.  of  London,  XLVIII, 

1896-97,  47. 
Pelon,  H.,  Des  ruptures  dites  spontanees  du  coeur.     Prog,  med., 

Paris,  VII,  1898,  385-387- 
Amyot,  J.,  Ruptured  Heart.     Canad.  Pract.,  Toronto,  XXIII, 

1898,  441. 


144  THE  SURGERY  OF  THE  HEART 

Meshiret,  Un  cas  de  rupture  spontande  du  coeur.     Jour,  de  med. 

de  Bordeaux,  XXVIII,  1898,  103. 
Ghedini,  a.,  Atti.  delta  Acad.  d.  Sci.  med.  e  nat.  in  Firenze,  LXXII, 

1897-98,  133-168;  I  pi. 
Hampeln,    p.,   Ueber  Herz   und   Aortenruptur.     St.   Petersburg 

Med.  Woch.,  XV,  1898,  419-422. 
Nebolyuboff,  Idiopathic  Rupture  of  the  Heart.     Dnervmk,  Obsh. 

Vrach.  Pri.  Imp.  Kazan  Univ.,  1898,  140-42. 
Newton,  Medical  Record,  June  17,  1899. 
Sutcliffe,  J.,  A  Case  of  Rupture  of  the  Heart.     Brit.  Med.  Jour., 

London,  1900,  I,  142. 
Kalenberg,  a.,  a  Case  of  Rupture  of  the  Heart.     Indian  Med. 

Rec,  Calcutta,  XVIII,  1900,  78. 
HuYGHE,  Deux  cas  de  rupture  du  coeur.     Nord.  med.,  Lille,  VII, 

1900,  74-77. 
Goodman,  P.  T.,  Case  of  Spontaneous  Rupture  of  the  Heart  and 

haemorrhage  into  the  Pons  Varolii.  Lancet,  London,  1900,  I, 

1067. 
EsHNER,  A.  A.,  Med.  Dial.,  II,  1900,  201. 
Prochazka,  Fr.,  Casop.  lek.  cesk.  Praha,  XI,  1901,  532-535;  587- 

591- 
Bergmann,  Ein  Fall  von  subcutaner  traumatischer  Ruptur  des 

Herzens  und  Herzbeutels.    Monatschr.  }.  Unjallheilk.,  Leipzig, 

VIII,  1901,  15-17. 
FiEROFF,  J.  M.,  Sur  les  ruptures  traumatiques  du  coeur.     Med. 

Obozr.  Mask.,  LV,  1901,  352-357. 
Durst,   F.,   Ruptura   traumatica  cordis   (atrii  sin.);    haemoper- 

cardium.      Liecnicki    Viestnik    Zagreb,    XXIV,    1902,    223- 

224. 
Thomson,  E.  M.,  A  Case  of  Rupture  of  the  Heart.    Brit.  Med. 

Quart.,  London,  I,  1902,  453. 
Bergmann,   Ein  Fall  von  subcutaner  traumatischer  ruptur  des 

Herzens,  und  Herzbeutels.     Monatschr.  }.  Unjallheilk.,  Leip- 
zig, 1901,  VIII. 
Fleroff,  J.  M.,  Sur  les  ruptures  traumatiques  du  coeur.     Med. 

Obozr.,  Moskow,  1901,  LV,  352-357. 


CARDIOCLASIA  145 

Procharzka,  Fr.,  Dcs  ruptures  spontan^es  du  coeur.  Cassop.  lek. 

cesk.  Praha,  1901,  XL,  532-535;  587-591- 
Durst,  F.,  Ruptura  traumatica   cordis    (atriisin)    haemopericar- 

dium.     Liecnicki  Viestnik  Zagreb,  1902,  XXIV,  223-224. 
Thomson,  Eric  M.,  A  case  of  rupture  of  the  heart.     Brit.  Med. 

Jour.,  London,  1902,  I,  453. 
Slajmer,  E.,  Contribution  a  la  casuistique  de  la  blessure  du  coeur 

avec  consideration  speciale  des  corps  etrangers.     Liecnicki 

Vestnik  Zagreb,  1902,  XXIV,  305-309,  2  fig. 


CHAPTER  VII 
CARDIORRHAPHY—CARDIOTOMY— HEART   SUTURES 

There  is  probably  no  organ  or  disease  about  which  so 
much  has  been  said  and  written,  with  so  Httle  accompHshed, 
as  the  heart  with  its  diseases. 

Historical  (1871-1903). — Until  1871,  when  Callender  re- 
moved a  needle  from  the  heart,  there  is  no  recorded  case  of 
human  heart  injury  in  which  anything  surgical  was  attempted. 
He  was  succeeded  by  Goodheart,  who  cured  a  case  of  hydatids 
of  the  heart  by  a  surgical  operation  in  1876. 

The  heart  may  be  injured  even  to  the  point  of  laceration 
without  injury  to  the  pericardium,  and  vice  versa.  Both, 
however,  are  found  wounded  in  either  event,  whether  by 
direct  or  oblique  contact.  A  penetrating  wound  of  the  heart 
may  occur  in  its  base  from  above,  without  injury  to  the  peri- 
cardium. The  right  ventricle  is  more  frequently  injured  than 
the  left,  and  the  mortality  greater  in  the  left.  The  auricles 
^re  protected  by  the  sternum. 

Loison  says  that  death  varies  with  the  position,  size, 
and  character  of  wound,  and  in  general  85  per  cent,  of  all 
heart  wounds  are  fatal. 

It  is  said  that  a  large  proportion  of  deaths  are  due  to 
effusion  of  blood  into  the  pericardial  sac,  causing  over- 
distention.  This  is  hardly  probable  when  the  pericardium 
is  incised  or  lacerated.  Reports  of  death  from  heart  injury 
are  very  untrustworthy  unless  verified  by  autopsy. 

Billroth  condemned  any  attempt  to  suture  wounds  of 
the    heart,     Riedinger    (1884),    Tillmanns,    Rosenthal,    Del 


IKt 


CARDIORRHAPHY-^ARDIOTOMY — HEART    SUTURES       I47 

Vecchio,  Solomoni,  and  Bode  each  discouraged  any  attempt 
whatever  at  suturing  wounds  of  the  heart. 

Stevenson  (1887),  concerning  heart  wounds  in  war,  says 
that  no  method  of  treatment  is  hkely  to  be  of  permanent 
service  towards  their  cure. 

Druitt  ("  Surgery,"  1867,  page  456)  says  that  "  opium  is 
the  only  available  remedy  "  in  injuries  of  the  heart,  wdiile 
Stephen  Smith,  as  late  as  1887  (page  257  "  The  Principles  and 
Practice  of  Operative  Surgery  "),  says  the  first  aim  is  clot  and 
to  induce  it,  and  that  fluid  should  be  drawn  oiT  with  a  tro- 
car. He  does  not  mention  suturing  or  anything  surgical, 
but  says  (page  277,  "  Operative  Surgery  ")  that  "  the  only 
operation  on  the  heart  and  pericardium  is  undertaken  for 
dropsy." 

Ashhurst  (International  Encyclopedia,  Vol.  VII,  page 
813)  says  that  there  is  nothing  to  be  done  in  wounds  of  the 
heart.     This  statement  was  made  as  late  as  1889. 

AVharton  and  Curtis  ("Surgery,"  1898,  page  878)  say,  con- 
cerning foreign  bodies  in  the  heart,  that  their  removal  should 
be  attempted  if  their  position  can  be  located  and  their  pres- 
ence causes  marked  disturbances.  Da  Costa  says  that  suture 
in  case  of  laceration  of  the  heart  should  be  attempted  and 
that  fine  silk  should  be  used.  Paget  ("  Surgery  of  the  Chest," 
page  373,  1897)  says  small  wounds  do  not  need  suture  and 
large  ones  give  no  chance  for  it. 

Makins  (1901,  "Surgical  Experience  in  South  Africa," 
pages  383,  384)  says  that  perforating  w^ounds  of  the  heart  were 
probably  fatal  in  all  instances,  but  that  several  cases  occurred  in 
which  the  surface  of  the  heart  was  scored  by  bullets,  and  that 
in  the  case  of  Cheatle  death  resulted  from  suppurative  peri- 
carditis; both  the  auricular  and  ventricular  walls  had  been 
scored.  Makins  believes  that  death  was  often  due  to  sud- 
den stoppage  of  the  heart  and  not  haemorrhage  from  it.  He 
reports  six  interesting  cases  of  gunshot  wounds  of  tissues 
in  close   proximity  with  the  heart,   as   shown  by  autopsy, 


148  THE  SURGERY  OF  THE  HEART 

demonstrating  their  influence  upon  the  action  of  both  the 
heart  and  lungs. 

The  history  is  of  more  or  less  importance,  and  while  there 
is  but  little  time,  if  any  at  all,  to  secure  a  history  in  cases 
of  emergency,  it  should  be  accurately  detailed  ill  cases  of 
election.  To  know  the  position  of  the  body,  whether  erect 
or  recumbent,  at  the  time  of  injury,  will  often  enable  the 
character  of  the  injur}-  to  be  more  accurately  determined,  as 
the  heart  changes  its  position  materially  with  these  postures. 

Weapon,  Knife  or  Gun. — In  the  case  of  wound  with  a  knife, 
the  characters  of  the  blade,  whether  sharp  or  blunt-edged, 
pointed  or  rounded  at  the  end,  narrow,  thin,  wide  or  thick, 
are  all  of  the  greatest  importance.  The  size  of  the  gun,  the 
character  of  the  ball,  one  or  more  in  number,  whether  of  lead 
or  steel,  soft  or  hard,  jacketed  or  not,  the  distance  it  travelled, 
and  the  angle  at  which  it  entered  the  body,  are  of  importance. 
Age,  sex,  and  general  physical  condition  at  the  time  of 
injury  are  to  be  noted,  also  whether  other  injuries  have  been 
inflicted  upon  the  body  at  the  same  time.  Note,  too,  ex- 
posure (if  any)  of  the  body  to  the  sun,  heat,  cold,  rain,  or 
wind,  and  the  time  of  injury  following  the  eating  of  a  meal. 

Comphcations  such  as  new  growths,  disease,  deformity 
in  general,  or  of  the  chest  in  particular,  are  quite  common. 

Symptoms. — External  signs  of  injury  may  or  may  not  be 
present.  If  present,  there  may  be  puncture,  laceration,  con- 
tusion, or  slight  or  extensive  ecchymoses. 

Crepitus  may  be  present;  if  so,  it  may  be  due  to  a  fract- 
ured rib  or  cartilage  or  to  emphysema.  These  may  exist 
without  external  manifestations.  A  foreign  body  may  induce 
crepitus. 

Haemorrhage  may  be  of  an  oozing  character,  it  may 
pulsate  or  flow  steadily,  mildly  or  excessively,  and  its  char- 
acter, whether  venous  or  arterial,  cannot,  as  a  rule,  be  de- 
termined. If  pulsating,  it  may  be  due  to  the  escape  of  blood 
from  the  heart  or  the  internal  mammary  or  intercostal  artery 


CARDIORRHAniY— CARDIOTOMY— IIEARI'   SUTURES       I49 

or  one  or  more  of  the  pulmonary  vessels.  One  or  all  of  these 
may  be  injured  at  the  same  time,  with  or  without  pulsating 
hemorrhage.  The  haemorrhage  may  be  exposed  or  concealed 
(external  or  internal),  single  or  combined,  with  or  without 
dulness  in  either  event.  If  there  is  dulness  upon  percussion, 
the  area  increases  with  increased  ha^nnorrhage,  which  may 
escape  into  a  cavity  of  the  chest  or  that  of  the  abdomen. 
The  heart's  action  becomes  more  rapid,  irregular,  and  feeble, 
threadlike  or  tumultuous.  Its  sounds  are  less  distinct,  be- 
coming more  indistinct  as  haemorrhage  increases,  whether  it 
be  concealed  or  exposed.  There  is  sometimes  to  be  heard 
a  metallic  tinkling  or  whizzing  sound,  resulting  from  the 
air  in  the  pericardium. 

Nietert  says:  "  I  have  observed  and  operated  upon  four 
cases  of  penetrating  wounds  of  the  pericardium  in  which  there 
was  bleeding  into  the  pericardial  sac.  In  these  four  cases 
there  was  a  communication  of  the  sac  with  the  pleural  cavity, 
and  in  each  instance  the  splashing  sound  was  audible.  I 
conclude,  therefore,  that  the  absence  of  the  sound  is  due  to 
increased  intrapericardial  pressure,  produced  by  an  accumu- 
lation of  blood.  This  accumulation  is  due  to  the  absence 
of  an  avenue  of  escape,  there  being  no  communication  with 
the  pleural  cavity.  Therefore,  the  splashing  sound  audible 
over  the  region  of  the  heart,  in  injuries  of  this  kind,  seems 
to  be  an  important  sign  in  connection  with  the  diagnosis, 
as  it  determines  whether  the  pericardial  sac  communicates 
with  the  pleural  cavity  or  not." 

Cyanosis  is  usually  present,  varying  in  degree,  depend- 
ing upon  the  size  of  the  wound  and  amount  of  haemorrhage 
and  interference  with  respiration. 

Dextrocardia. — The  heart  may  not  be  in  its  normal  posi- 
tion, and  for  that  reason  escape  injury  when  it  occurs  in  the 
heart's  normal  position,  or  the  position  commonly  known  to 
be  that  of  the  heart.  Sometimes  the  heart  is  pushed  forward 
as  a  result  of  fluid  behind  it.     Orthodiagraphy  may  be  used 


150  THE  SURGERY  OF  THE  HEART 

to  determine  the  position  of  the  heart  or  the  presence  of  a 
foreign  body.  Moritz  mentions  sixteen  cases  in  which  he 
could  determine  the  oiitHnes  of  the  heart  with  the  x  ray 
{Munchcncr  Med.  Woch.,  January  7,  1902.) 

The  temperature  is  usually  subnormal.  It  may  be  normal 
or  it  may  be  higher,  depending  upon  the  amount  of  shock  from 
the  injury  itself,  or  excitement  incident  to  it,  or  both,  exposure 
to  heat,  cold,  water,  air.  the  sun,  or  rough  handling.  Perspi- 
ration may  be  mild  or  profuse,  or  it  may  be  absent  entirely. 
Pallor  may  vary  in  degree,  or  it  may  be  absent,  but  is  usually 
present. 

Respiration  may  be  difficult  and  vary  in  degree.  The 
difficulty  is  supposed  to  be  due  to  pressure  upon  the  lungs 
by  the  escape  of  blood  into  the  pericardial  or  pleural  cavities, 
but  it  may  be  present  without  these  conditions. 

Sighing,  yawning,  and  gasping  may  manifest  themselves 
separately  or  combined  at  any  time  between  the  injury  and 
recovery  or  dissolution.  Facial  expression  is  markedly 
changed,  indicating  great  distress  and  anxiety,  and  this  sign 
is  usually  present.  Mental  excitement  varies  from  a  mild 
degree  to  that  of  delirium  and  unconsciousness.  Delirium 
coming  on  after  a  few  days  indicates  pysemic  cardiac  abscess. 

The  general  nervous  system  suffers  greatly  as  a  rule. 
There  is  more  or  less  muscular  contraction,  with  a  slight  hack- 
ing cough  and  restlessness  to  the  point  of  general  convul- 
sion. The  patient  will  sometimes  claw  at  his  clothing  or,  if 
lying  upon  the  ground,  will  pull  at  the  grass,  dirt,  or 
weeds,  or  anything  he  can  grasp. 

Treatment.  (1)  Sanitary — Stimulants  should  be  given  with 
great  caution,  especially  before  the  opening  in  the  heart  is 
closed  with  suture.  The  amount  of  bleeding  from  an  opening 
in  the  heart  is  greatly  influenced  by  the  strength  and  number 
of  beats.  A  recumbent  position  and  perfect  quietude  should 
be  maintained  with  the  patient  and  his  surroundings. 

Hot  or  cold  draughts  of  air.  rain,  snow,  and  the  sun's 


Plate  XVIII. 


X  110. 
AnGEIO'MA. 


>•     '    "^Sfe^T'^'  .    .'j/ 


X   2.jU. 

Myxomatous  Tissue. 


(Chapter  on  Benign  Tumors.) 


CARDIORRHAPHY — CARDIOTOMY — HEART   SUTURES       151 

rays  should  be  excluded.  Artificial  heat  should  be  applied, 
and  tight,  unclean,  or  superfluous  garments  removed.  Ex- 
clude all  but  necessary  attendants  and  relieve  pain  with  hypo- 
dermic injections  of  morphine.  Transportation  of  the  patient 
should  not  be  attempted.  If  necessary,  it  should  be  done 
on  a  stretcher  carried  by  men. 

(2)  Surgical — Aseptic  principles  should  be  applied  in 
every  step  of  the  operation  and  throughout  the  care  of  the 
wound.  No  time  should  be  lost  in  deciding  upon  what  is 
to  be  done  in  each  individual  case.  If  the  patient  is  uncon- 
scious, anaesthesia  will  not  be  necessary.  In  many  cases  in 
which  the  patients  are  conscious  anaesthesia  cannot  be  induced 
because  the  loss  of  time  necessary  to  produce  anaesthesia  would 
be  fatal.  There  can  be  no  fixed  rule  as  to  whether  or  not 
anaesthesia  should  be  produced,  each  case  having  its  individ- 
uality. Morphine  given  subcutaneously  at  time  of  injury  will 
probably  prove  efficacious  in  lessening  pain  and  shock  in 
patients  who  cannot  bear  anaesthetics. 

If  possible,  reach  the  opening  in  the  heart  without  open- 
ing the  pleural  cavity,  but  if  the  pleural  cavity  has  been  opened 
by  the  primary  injury,  the  opening  should  be  enlarged  to 
admit  of  ample  room  to  expedite  suturing. 

Giardano  advises  following  the  canal  of  the  wound  to 
the  pericardium  and  heart  rather  than  making  an  osteo- 
plastic flap,  as  it  might  be  sufficient  to  stop  haemorrhage 
through  a  small  opening  in  this  way.  If  this  course  is  not 
followed,  a  semicircular  incision  is  made  to  divide  the  soft 
tissues  overlying  the  sternum.  The  cartilages  of  the  fifth  and 
sixth  ribs  on  the  left  side  are  severed  near  the  sternum,  then 
by  means  of  the  rongeur  a  sufficient  portion  of  the  sternum 
is  removed  to  bring  the  cut  in  the  pericardium  plainly  into 
view.  If  necessary,  the  opening  in  the  sternum  may  be  en- 
larged. The  wound  in  the  pericardium  may  also  be  enlarged 
to  facilitate  the  work.  Gelatin  given  subcutaneously,  by  the 
stomach,  or  by  the  rectum,  is  said  to  be  beneficial  in  arrest- 


152  THE  SURGERY  OF  THE  HEART 

ing  haemorrhage  from  wounds  of  the  heart  as  in  other  locali- 
ties. 

Historical  Surgery  of  the  Pericardium. — Baron  Larrev 
(1798)  was  the  first  deliberately  to  plan  the  removal  of,  and 
to  remove,  fluid  from  the  pericardial  space.  This  he  did  by 
introducing  a  hollow  needle  between  the  seventh  rib  and  the 
ensiform  cartilage.  (Memoires  de  Chirurgie,  Milan,  t.  Ill, 
page  458.) 

The  best  anatomical  route  would  appear  to  be  between 
the  sixth  and  seventh  ribs,  one  inch  to  the  left  of  the  sternal 
margin.  The  internal  mammary  artery  is  a  little  external 
to  the  side  of  the  sternum,  and  the  intercostal  artery  at  the 
lower  margin  of  the  rib. 

Romero  incised  the  pericardium  in  1801  with  a  needle, 
and  aspirated  it  in  three  cases  in  1819,  in  two  of  which  the 
patients  recovered.  Jowett  (1827),  Wheelhouse  (1866),  and 
Tiele  (1869),  each  punctured  the  pericardium.  Goodhart 
(1876)  cured  a  case  of  hydatids  of  the  pericardial  sac  by  as- 
piration. West  (1883)  collected  eighty  cases  of  aspiration 
of  the  pericardium  for  various  causes.  Leyden  (1881)  was 
the  first  to  make  an  incision  in  the  pericardium  to  evacuate 
fluid.    In  his  case  the  fluid  was  pus  and  the  patient  recovered. 

Riolan  was  the  first  to  trephine  the  sternum  for  the  pur- 
pose of  opening  the  pericardial  sac.  John  C.  Warren  (1852) 
was  the  first  American  to  remove  fluid  from  the  pericardia] 
sac  with  a  needle  successfully.  Trousseau  did  not  give  Larrey 
the  credit  of  being  the  first  to  open  the  pericardial  sac  with 
a  needle.  Trousseau  not  only  adopted  the  method  of  Larrey 
and  Desault,  but  the  point  of  puncture  also. 

The  heart  is  pushed  forward  in  the  great  majority  of 
cases  by  fluid  within  the  pericardium.  This  of  itself  should 
preclude  the  advisability  of  plunging  a  trocar  into  the  peri- 
cardial sac,  for  the  reason  that  the  needle  must  of  necessity 
pass  through  the  heart  to  reach  the  fluid  behind  it.  ("Surgery 
of  the  Pericardium.") 


CARDIORRIIAPIIY — CARDIOTOMY — HEART   SUTURES       I  53 

Wyman  reports  a  case  in  which  the  bursting  of  a  circular 
saw  tore  away  a  portion  of  the  fifth  costal  cartilage  and  fifth 
rib.  There  was  an  opening  in  the  pericardium  and  apex  of 
the  heart.  The  latter  protruded.  He  sutured  the  pericar- 
dium with  catgut  and  the  patient  recovered.  {Deut.  Med. 
Woch.,  August  II,  1898.) 

Reed  R.  Harvey,  during  the  year  1887,  had  a  case  of 
stab  wound  in  the  left  chest  over  the  apex  of  the  heart.  He 
removed  a  section  of  the  sixth  rib  afid  the  clots  in  the  peri- 
cardial sac  and  sutured  the  pericardium  and  cutaneous  struct- 
ures. The  patient  is  acting  as  a  policeman  in  Shelby,  Ohio. 
(Personal  communication.) 

Dalton,  H.  C.  (1891,  September  6,  Annals  of  Surgery), 
sutured  the  pericardium  for  a  stab  wound,  with  recovery. 

Resuscitation — There  are  numerous  ways  suggested  to 
induce  return  of  the  heart's  action.  Among  those  most  com- 
monly practised  are  pressure,  manipulation,  subjecting  the 
heart  to  a  saline  solution,  cold  or  hot  air,  needling,  aspira- 
tion, electricity,  and  the  exhibition  of  adrenalin. 

Pressure. — This  may  be  accomplished  by  compressing  the 
chest  wall  or  diaphragm  when  the  abdomen  is  open. 

Manipulation  is  done  with  the  fingers  or  hand  when  the 
chest  is  open.  A  part  or  all  of  the  heart  may  be  held  in  the 
palm  of  the  hand  and  gently  pressed  with  each  systole.  If 
the  opening  in  the  pericardium  is  not  sui^cient  to  permit 
of  the  entire  heart  being  grasped  in  the  palm  of  the  hand, 
the  apex  alone  may  be  grasped  by  the  thumb,  index,  and 
second  fingers  and  gently  compressed  with  each  systole,  or 
about  eighty  times  a  minute. 

Saline  solution. — The  immersion  of  the  heart  in  a  normal 
salt  solution  has  been  known  to  stimulate  the  cardiac  fibres 
to  contraction.  It  may  be  injected  into  the  pericardial  sac 
through  a  hollow  needle  or  it  may  be  introduced  with  a 
syringe  through  a  rent  in  the  pericardium. 

Cold  or  hot  air  has  also  been  known  to  stimulate  the 


154  THE  SURGERY  OF  THE  HEART 

heart's  action  when  once  it  has  become  quiescent.  The 
blowing  of  air  with  the  mouth  or  bellows  has,  in  a  few  in- 
stances, also  stimulated  cardiac  action,  when  once  it  had 
ceased. 

Needling. — The  introduction  of  a  small  needle  into  the 
wall  of  the  heart  has  been  shown  to  cause  the  heart  to  renew 
its  contraction  after  it  had  ceased  for  several  seconds. 

Aspiration. — Westbrook  (New  York  Medical  Record, 
1882,  Vol.  II,  page  705)  abstracted  blood  from  the  right  heart 
for  simple  distention  and  to  excite  a  return  of  its  action. 

Maag  had  a  case  of  death  from  chloroform  narcosis,  but 
before  the  patient  died  he  made  use  of  the  pressure  method 
of  resuscitation,  i.e.,  manual  compression  of  the  heart  and 
artificial  respiration.  For  the  latter  purpose  air  was  blown 
into  the  lungs  through  a  tracheal  cannula.  Half  an  hour 
elapsed  before  they  could  perceive  natural  respiration.  For 
one  hour  the  breathing  was  deep  and  regular,  the  heart  beats 
were  powerful,  seventy  per  minute.  An  hour  later,  the  patient, 
apparently  saved,  was  put  to  bed,  although  still  unconscious. 
In  a  few  minutes  respiration  ceased  and  could  not  be  restored. 
The  heart  continued  to  beat  for  eight  hours  after,  and  then 
stopped  suddenly;  the  temperature  fell  gradually  during  this 
time.  Maag  resorted  to  the  pressure  method  in  this  case 
ten  or  fifteen  minutes  after  all  pulse  and  respiration  had 
stopped;  the  patient  was  cold  and  cyanotic.  Resuscitation 
was  successful,  even  though  the  patient  died. 

A  personal  communication  from  E.  Lanphear  states  that 
he  resuscitated  a  patient  from  chloroform  narcosis  by  manual 
compression  of  the  heart.  The  patient  was  brought  to  con- 
sciousness and  was  able  to  converse,  but  died  one  hour 
later. 

Electricity. — The  negative  pole  of  a  faradic  current  ap- 
plied to  any  portion  of  the  vagi  will  stimulate  the  heart's 
action.  Muhlberg  and  Crile  believe  that  adrenalin  is  a  most 
powerful  cardiac  stimulant,  in  fact  the  most  powerful  of  any 


CARDIORRHAPHY — CARDIOTOMY— HEART  SUTURES   I  55 

known  at  the  present  time.  (See  Chapter  on  Experimental 
Heart.) 

Causes  of  Death — Primary.    Shock,  haemorrhage. 

Secondary.  Carditis,  endocarditis,  pericarditis,  pleuritis, 
pneumonitis,  embolism  (air  or  clot),  abscess,  aneurysm,  ex- 
haustion. 

Primary  shock  is  the  term  applied  to  that  class  of  heart 
injuries  which  produce  instant  death  without  much  if  any 
loss  of  blood. 

Haemorrhage  is  the  cause  of  death  in  the  greater  number 
of  cases.  Life  may  be  maintained  several  hours  after  the 
heart  has  received  a  fatal  injury.  In  such  a  case  the  proba- 
bilities are  that  the  laceration  is  limited  to  the  external  sur- 
face of  the  heart.  Haemorrhage  may  also  result  from  an 
injury  to  a  small  branch  of  one  or  both  of  the  coronary  ar- 
teries or  a  small  puncture  through  the  endocardium,  regard- 
less of  the  size  of  the  opening  on  the  external  surface  of 
the  heart. 

Secondary  carditis  frequently  results  from  lacerations  or 
contusions  and  may  be  local  or  general,  varying  in  degree 
of  seriousness. 

Endocarditis  occurs  perhaps  more  frequently,  and  is  many 
times  associated  with  carditis.  It  may  be  the  result  of  car- 
ditis or  it  may  cause  it.  If  there  is  endocarditis  without  in- 
jury to  the  endocardium,  it  is  the  result  of  carditis,  but  it 
more  frequently  occurs  as  the  result  of  direct  injury. 

Pericarditis  is  probably  the  most  frequent  complication, 
and  it  may  follow  cardiac  injury  of  any  degree,  at  any  time, 
in  a  circumscribed  or  general  way.  If  it  is  present  at  the 
time  of  operation,  the  pericardium  should  be  left  open  and 
provided  with  a  strip  of  gauze  for  drainage.  In  such  cases  the 
pericardium  will  become  adherent  to  the  heart. 

Pleuritis  resulting  in  empyema  is  of  frequent  occurrence. 
The  pleura  may  be  involved  without  empyema.  In  either 
case  inflammation  of  the  pleura  may  be  a  complication  with- 


156  THE  SURGERY  OF  THE  HEART 

out  the  pleura  having  received  direct  injury.     It  may  be  cir- 
cumscribed or  general. 

Pneumonitis  is  a  serious  complication,  resulting  from 
direct  injury  or  secondary  to  injury  to  the  heart.  The 
left  lung  is  more  frequently  involved  than  the  right,  and  the 
extent  of  involvement  may  be  of  any  degree. 

Embolism  (air  or  clot)  may  be  fatal  at  any  time  during 
convalescence.  It  is  to  be  especially  feared  in  all  cases  in 
which  the  injury  has  extended  to  the  cavity  of  the  heart; 
otherwise  it  is  not  likely  to  occur. 

Air  entering  the  heart  during  the  closure  of  a  heart  wound 
is  not  so  much  feared  in  later  years.  It  is,  however,  to  be 
considered  and  guarded  against.  Its  entrance  into  the  heart 
may  cause  immediate  or  subsequent  death.  It  may  enter 
the  heart  before  the  closure  of  the  opening  or  it  may  enter 
subsequently,  if  the  sutures  should  tear  out  or  become  ab- 
sorbed or  break  before  union  has  been  complete. 

Abscess  may  occur  in  the  wall  of  the  heart  within  the 
pericardial,  pleural,  or  mediastinal  space;  wherever  it  may 
exist,  free  drainage  should  be  resorted  to. 

Aneurysm  has  been  observed  in  the  cicatrix  of  cardiac 
wounds.  It  may  occur  and  terminate  fatally  at  any  time,  or 
it  may  develop  slowly  and  may  or  may  not  result  in  disso- 
lution. 

Exhaustion  is  usually  due  to  one  or  more  of  these  com- 
plications of  any  degree  to  that  of  fatal  termination. 

The  accompanying  fifty-six  cases  of  heart  suture  with 
twenty  successes  are  a  glowing  tribute  to  the  many  achiev- 
ments  already  attained  during  the  nineteenth  century,  and, 
coming  as  it  does  so  near  its  close,  one  is  led  to  believe  that 
the  twentieth  century  will  not  be  far  advanced  before  the 
problems  of  surgery  of  the  heart  will  be  determined  and 
become  fixed. 

That  incisions,  lacerations,  and  pvmcture  of  the  heart 
from  any  cause  will  be  successfully  sutured,  superficial  ab- 


CARUIORRHAPIIY—CARDIOTOMY— HEART   SUTURES       I  57 

scesses  and  cysts  evacuated  by  incision,  foreign  bodies,  clots, 
and  pathogenic  organisms  removed  from  the  wall  or  the  cavi- 
ties of  the  heart,  there  can  be  but  little  doubt. 

Callender  (1871)  extracted  a  needle  imbedded  in  the 
human  heart,  and  Roswell  Park  (1877)  unintentionally 
aspirated  a  myocardial  abscess.  These  are  probably  the  first 
recorded  cases  in  which  anything  surgical  has  been  done  with 
the  human  heart. 

Farina  (1896)  reports  the  first  recorded  case  in  which 
sutures  were  applied  for  a  traumatic  opening  in  the 
cardiac  wall,  and,  although  the  patient  died  on  the  fifth  day 
from  bronchopneumonia,  much  credit  should  be  given  the 
operator. 

The  wound  was  made  with  a  dagger  entering  just  above 
the  margin  of  the  left  sixth  rib  near  the  sternum.  An  open- 
ing one-fourth  of  an  inch  in  length  was  made  in  the  right 
ventricular  wall.     Three  stitches  were  taken  with  silk. 

Cappelen  (1896)  records  a  case  of  stab  wound  of  the  heart 
through  the  fourth  left  intercostal  space  in  the  middle  axillary 
line,  inflicting  a  penetrating  wound  four-fifths  of  an  inch  in 
length,  not  into  the  left  ventricle.  The  operation  was  done 
one  hour  later.  Death  ensued  several  days  after,  from 
pericarditis.  A  branch  of  the  coronary  artery  had  been 
accidentally  cut  during  the  operation,  probably  with  the 
needle. 

Rehn  (1896)  also  sutured  a  stab  wound  of  the  heart  of 
a  man  twenty-two  years  old,  the  opening  being  in  the  right 
ventricle.  The  knife  entered  the  fourth  left  intercostal  space 
near  the  sternum.  Three  sutures  were  applied  twenty-six 
hours  after  the  injury.  Although  empyema  developed,  the 
patient  recovered.  This  is  the  first  recovery  to  follow  sutur- 
ing the  heart  for  injury. 

Parrozzani  (1897)  had  the  second  case  to  end  in  recovery 
from  heart  suturing  for  a  three-quarter  inch  incision  in  the 
left  ventricle  five  hours  after  the  injury.     The  knife  entered 


158  THE  SURGERY  OF  THE  HEART 

the  seventh  left  intercostal  space  in  the  middle  axillary  line. 
No  anaesthetic  was  given. 

Parrozzani  again  records  a  case  in  which  suturing  of  a 
three-quarter  inch  puncture  in  the  right  ventricle  was  done 
through  the  third  left  intercostal  space  one-half  hour  after 
the  injury.  Death,  on  the  second  day,  was  due  to  a  cut  in 
the  interventricular  saeptum.  No  anaesthetic  was  given.  The 
heart  wound  was  firmly  closed. 

Funna  (1898)  reports  a  stab  wound  under  the  left  nipple, 
the  weapon  entering  the  apex  of  the  heart,  but  not  the  cardiac 
cavity.  Sutures  were  applied  several  hours  after  the  injury. 
Empyema  followed,  but  recovery  took  place.  No  anaesthetic 
was  used. 

Parlavecchio  (1898)  mentions  the  case  of  a  young  man 
who  walked  a  quarter  of  a  mile  with  a  V-shaped  penetrating 
knife  wound,  three  and  one-half  inches  long,  in  the  wall  of 
the  left  ventricle,  through  the  fifth  left  intercostal  space. 
Eight  hours  after  the  injury  the  chest  was  opened  and  four 
interrupted  silk  sutures  were  applied.  Chloroform  narcosis 
was  employed,  and  recovery  was  uneventful. 

Ninni  (1898)  reports  the  case  of  a  man  thirty  years  of 
age  who,  after  receiving  a  knife  wound  in  the  left  fifth 
intercostal  space,  walked  two  hundred  steps  with  a  wound  in 
the  anterior  wall  of  the  left  ventricle  near  the  apex  twenty- 
five  mm.  in  length.  Without  anaesthesia  the  chest  was  opened 
and  the  pleura  incised,  with  the  escape  of  much  clotted 
blood.  Two  silk  sutures  were  used  to  close  the  wound  in 
the  heart,  and  continuous  sutures  to  close  the  pericardium. 
The  patient  died  while  the  pleural  cavity  was  being  cleared 
of  clots. 

Giordano  (1898)  records  a  case  of  an  incision  four-fifths 
of  an  inch  in  length  in  the  left  auricle  in  which  he  applied 
four  stitches  one-half  hour  after  the  injury.  The  external 
wound  was  in  the  second  left  intercostal  space.  No  anaes- 
thetic was  used.     Death  took  place  on  the  nineteenth  day. 


Plate  XIX. 


'^ 


X  440. 

Myoma. 


X  IGO. 

Rhabdomyoma. 


(Chapter  on  Benign  Tumors.) 


CARDIORRIIAPIIV— CARDIOTOMY — HEART   SUTURES       I  59 

Empyema  and  abscess  in  the  right  lung  were  found,  but  the 
wound  in  the  heart  had  completely  united. 

Nicolai  (1898)  took  four  stitches  in  a  wound  of  the  right 
ventricle  one  and  one-half  hours  after  the  injury.  The  ex- 
ternal wound  was  in  the  fourth  left  intercostal  space,  midway 
between  the  margin  of  the  sternum  and  the  nipple.  Chloro- 
form was  used.    Death  occurred  twelve  hours  later. 

Tuzzi  (1898)  records  a  case  in  which  there  were  two 
wounds  of  the  heart,  one  penetrating  and  one  non-penetrat- 
ing. The  external  wound  w-as  in  the  fourth  left  intercostal 
space.  No  chloroform  was  used,  and  death  occurred  on  the 
twenty-second  day  from  empyema  and  pericarditis. 

Longo  (1898)  records  a  case  of  injury  through  the  fifth 
left  intercostal  space,  two-fifths  of  an  inch  internal  to  the 
nipple,  producing  an  opening  in  the  left  ventricle  necessitat- 
ing three  stitches.  The  operation  was  done  at  once  without 
an  anaesthetic.     Death  followed  in  fifteen  minutes. 

Williams  (1898)  reports  a  discovery  follownng  the  sutur- 
ing of  a  stab  w^ound  of  the  heart.  (Da  Costa,  "  Surgery,"  p. 
240.) 

Ramoni  (1898)  applied  four  stitches  in  two  wounds  of 
the  heart,  one  penetrating  and  one  non-penetrating.  The 
external  wound  was  at  the  third  left  cartilage,  four-fifths  of 
an  inch  from  the  sternum.  No  anaesthetic  was  used.  Re- 
covery followed. 

Marion  (1899)  sutured  a  gunshot  wound  in  the  heart,  with 
death. 

Rosa  (1899)  was  not  sure  that  a  stab  wound  of  the  left 
ventricle  wall  entered  the  cavity.  He  sutured  a  three-fifth 
inch  incision  without  anaesthesia  and  with  recovery. 

Horodimki  (1899)  sutured  an  incision  one  and  one-half 
ctm.  long  in  the  right  ventricle,  with  death. 

Maliszenski  (1899)  sutured  a  heart  wound,  with  death. 

Alaliszenski  (1899)  sutured  another  heart  wound,  with 
a  fatal  result. 


l6o  THE  SURGERY  OF  THE  HEART 

Bufnoir  (1899)  sutured  a  twenty-two  calibre  gunshot 
wound  of  the  right  ventricle.  The  ball  entered  the  fifth  left 
intercostal  space.  Death  followed.  The  necropsy  showed 
perforation  of  the  ventricle,  and  the  anterior  opening  only 
had  been  sutured. 

Pagenstecher  (1899)  records  the  case  of  a  man  seventeen 
years  old  in  which  he  applied  two  stitches  in  a  wound  of  the 
apex  of  the  left  ventricle,  sixteen  hours  after  the  injury, 
without  anaesthesia,  the  point  of  entrance  being  in  the  fourth 
left  intercostal  space,  beneath  the  nipple.  Recovery  took 
place. 

Nanu  (1900)  applied  two  interrupted  sutures  in  a  wound 
of  the  right  ventricle  two  ctm.  long,  the  point  of  entrance 
being  in  the  third  left  intercostal  space,  four  ctm.  from  the 
edge  of  the  sternum.  Death  occurred  on  the  fifth  day,  from 
infection  of  the  pericardium  and  pleura. 

Masseli  (1900)  sutured  a  wound  of  the  left  ventricle,  near 
the  apex,  one  and  one-half  hours  after  the  injury.  The  ex- 
ternal wound  was  below  and  internal  to  the  left  nipple,  cutting 
the  fifth  rib.     The  patient  died  twelve  hours  afterward. 

Fountain  (1900)  sutured  a  wound  twelve  mm.  long  in  the 
left  ventricle  with  continuous  and  interrupted  catgut,  six  hours 
after  the  injury,  using  chloroform,  with  recovery.  There  were 
six  external  wounds  with  scissors  between  the  third  and 
seventh  rib  in  the  cardiac  region. 

Nietert  (1901)  sutured  a  stab  wound  in  the  heart  three- 
fourths  of  an  inch  long.  Three  silk  sutures  were  used  to 
close  the  wound  in  the  right  ventricle.  Death  occurred  after 
twenty-five  hours. 

Vaughan  (1901)  applied  a  continuous  silk  suture,  seven 
stitches,  in  a  w^ound  of  the  left  ventricle  two  and  one-half 
ctm.  long,  forty-five  minutes  after  the  injur>'.  Ether  was 
used.  Death  of  the  patient  took  place  on  the  table  from 
haemorrhage  at  the  time  of  the  completion  of  the  operation, 
from  external  wounds  in  fifth  left  costal  cartilage  divided. 


CARDIORRHAniY— CARDIOTOMY — HEART   SUTURES       l6l 

Nietert  (1901)  applied  two  sutures  in  a  wound  of  the  left 
ventricular  wall.  It  was  doubtful  whether  the  cavity  had 
been  opened.     Recovery  took  place. 

Zerlehner  (1901)  reports  a  case  of  a  man  who  had  been 
stabbed  in  both  chest  and  abdomen.  The  chest  wound  pene- 
trated the  heart.  He  sutured  the  incision  in  the  wall  of  the 
left  ventricle.  The  patient  bled  to  death  by  reason  of  the 
five  sutures  being  torn  out  almost  immediately.  The  general 
condition  of  the  patient  was  such  that  he  would  have  un- 
doubtedly died  even  if  the  sutures  had  not  given  way. 

Ninni  (1901)  had  a  case  of  wound  of  the  right  auricle,  the 
entrance  being  in  the  chest  left  of  the  sternum;  the  patient 
died  in  four  days,  from  sepsis. 

Mignon  and  Sieur  (1901)  sutured  a  wound  of  the  right 
ventricle;  death  followed. 

Fontan  (1901)  sutured  a  wound  of  the  left  ventricle  with 
catgut.  Empyema  followed;  its  evacuation  was  made,  fol- 
lowed by  recovery. 

Brenner  (1901)  had  a  case  of  injury  to  the  left  of  the 
sternum,  near  the  sixth  cartilage,  the  right  ventricle  being 
injured.  The  patient  was  operated  upon  on  the  following 
day.  Death  took  place  on  the  table.  Degeneration  of  the 
heart  muscle  was  found. 

Watten  (1901)  records  a  case  in  which  the  missile  en- 
tered the  fourth  right  intercostal  space,  injuring  the  right 
ventricle,  producing  a  wound  from  three  to  four  ctm.  in 
length.  The  right  pleura  was  wounded.  Pneumothorax 
followed,  but  recovery  took  place. 

Lastaria  (1901)  had  a  case  in  w^hich  the  left  ventricle 
was  injured,  and  was  sutured.  Death  occurred  in  a  few 
days. 

Launay  (1902)  reports  a  case  of  a  pistol  ball  entering 
the  left  ventricle,  perforating  both  the  anterior  and  posterior 
walls  of  the  heart.  He  used  catgut  sutures  in  each  wound, 
and  recovery  took  place. 


l62  THE  SURGERY  OF  THE  HEART 

Raiisohoff  (1902)  had  a  case  of  non-penetrating  pistol 
wound  of  the  left  ventricle.     Death  took  place  on  the  table. 

Stewart,  G.  D.  (1902,  personal  communication),  had  a 
patient  with  an  injury  of  the  heart,  which  he  sutured.  It 
was  followed  by  death. 

Nietert,  H.  L.  (Surgery  of  the  Heart,  "  American  Journal 
of  Surgery  and  Gynaecology, "  St.  Louis,  1902,  xv,  1 51-153, 
"Philadelphia  Medical  Journal,"  1902,  ix,  790-793,  i  fig.) 
had  a  case  in  a  male,  aged  27,  penetrating  wound  of  left  chest. 
A  hurried  examination  showed  an  incision  wound  in  the  sixth 
interspace,  a  little  to  the  right  of  the  left  papillary  line ;  super- 
ficial area  of  cardiac  dulness  was  somewhat  increased  toward 
the  left;  there  was  absolute  flatness  posteriorly  over  the  area 
normally  occupied  by  the  lower  lobe  of  the  left  lung.  A  nor- 
mal vesicular  murmur  was  heard  over  the  entire  right  lung 
and  upper  portion  of  the  left  lung.  The  finger  being  intro- 
duced into  the  wound,  it  was  found  that  the  pericardium  had 
been  cut.  The  finger  was  then  introduced  through  the  incision 
in  the  pericardium  and  it  was  found  that  the  heart  also  had 
been  entered  by  the  knife.  In  order  further  to  explore  the 
wound  and  ascertain  its  true  nature  a  flap  was  made  including 
the  fifth  and  sixth  ribs  on  the  left  side  of  the  sternum.  The 
outlines  of  the  flap  were  as  follows :  The  first  incision  was 
made  along  the  lower  border  of  the  fourth  rib,  extending  for 
two  inches  outward  from  the  left  border  of  the  sternum.  A 
second  incision  was  made  along  the  lower  border  of  the  sixth 
rib  to  a  point  about  two  inches  to  the  left  of  the  sternum.  The 
outer  extremities  of  the  two  incisions  were  united  by  a  third 
incision.  The  fifth  and  sixth  ribs  were  divided  in  the  line  of 
the  outer  wound,  as  were  also  the  intercostal  muscles  and 
pleura.  The  entire  flap,  composed  of  skin,  muscles  and  ribs,  was 
forcibly  pulled  toward  the  right  side,  partly  breaking  the  car- 
tilages near  the  sternum.  (The  flap  was  a  modification  of  that 
devised  by  Rotter,  and  is  fully  described  above.)  Through 
this  opening  an  excellent  view  could  be  obtained  of  the  pericar- 


CARDIORRHAPHY— CARDIOTOMV — HEART  SUTURES   163 

clium  and  the  cut  in  it.  A  cut  about  three-quarters  of  an  inch 
in  length  was  seen  in  the  left  ventricle,  located  far  back.  Two 
interrupted  silk  sutures  were  introduced  by  means  of  a  highly 
curved  gut  needle.  The  wound  was  treated  as  an  infected  one 
and  drains  were  introduced;  one  in  pericardium  back  of  the 
heart  and  the  opening  in  the  pericardium  only  partly  closed; 
another  drain  was  placed  in  the  pleural  cavity.  The  osteoplas- 
tic flap  was  then  allowed  to  fall  back  into  position  and  sutured, 
except  at  point  of  drain.  Patient  was  unconscious  for 
several  days  after  the  operation.  During  this  time  he  was 
given  frequent  hypodermic  injections  of  strychnine  and  whis- 
key. The  drains  were  removed  on  the  fourth  day.  Patient 
made  an  uninterrupted  recovery.  The  conclusions  are:  i. 
That  gentle  manipulation  may  be  applied  without  producing 
shock;  2,  that  the  introduction  of  the  suture  produces  but  a 
slight  irregularity  in  the  heart's  action;  3,  that  heart  wounds 
heal  rapidly;  4,  intrapericardial  pressure  is  increased  even  if 
haemorrhage  occurs  during  diastole  alone;  5,  that  all  heart 
wounds  in  which  there  is  danger  of  fatal  haemorrhage  should 
be  sutured;  6,  if  the  wound  does  not  involve  the  pleura  the  ex- 
trapleural route  should  be  employed  as  described  above;  7,  if 
the  pleura  has  been  injured  the  intrapleural  method  should  be 
employed,  and  the  flap  devised  by  Rotter  is  the  best;  8,  al- 
though it  is  advisable  for  the  surgeon  to  familiarize  himself 
with  the  methods  of  operation  and  the  flaps  devised  by  the  dif- 
ferent operators  a  thorough  knowledge  of  the  anatomy  of  the 
region  is  most  essential,  and  each  operator  should  modify  the 
flaps  as  best  suits  his  case. 

REPORTS    OF    CASES    OF    SUCCESSFUL    SUTURING    BY    DIFFERENT    OPER- 
ATORS   WITH    VARIOUS    TERMINATIONS,    AND    THE    CONCLUSIONS 

By  L.  L.  Hill,  M.D.,  surgeon  to  the  Hill  Infirmary,  Mont- 
gomery, Alabama.    Personal  communication. 

Henry  Myrick,  a  negro,  thirteen  years  of  age,  of  rather 
delicate  appearance,  was  stabbed  at  five  o'clock  on  Sunday 


164  THE  SURGERY  OF  THE  HEART 

afternoon,  September  14,  1902.  About  six  hours  after  the 
injury  Drs.  Parker  and  Wilkerson  were  called,  and,  perceiv- 
ing the  nature  of  the  case,  advised  that  I  should  be  sent  for, 
and  upon  my  arrival  I  urged  an  immediate  operation.  To 
this  the  parents  readily  consented,  and  I  was  assisted  in  the 
operation  by  Drs.  Wilkerson,  Parker,  Michel,  R.  S.  Hill, 
Robinson,  and  Washington.  The  knife  blade  entered  the 
fifth  intercostal  space,  about  a  quarter  of  an  inch  to  the  right 
of  the  left  nipple,  and,  penetrating  the  apex  of  the  heart, 
passed  into  the  left  ventricle.  The  wound  was  about  three- 
eighths  of  an  inch  in  length,  and  from  it  came  a  stream  of 
blood  at  every  systole.  There  was  no  external  bleeding,  but 
his  general  condition  was  very  unfavorable.  The  radial  pulse 
was  almost  imperceptible,  and  the  heart  sounds  were  heard 
with  difficulty.  There  was  a  triangular-shaped  area  of  dul- 
ness.  He  had  dyspnoea  and  was  very  restless.  His  extremi- 
ties were  cold,  as  were  his  lips  and  nose.  When  aroused,  he 
answered  questions  intelligently,  though  his  countenance 
showed  great  distress.  Securing  two  lamps,  I  removed  the 
boy  from  his  bed  to  a  table  at  one  o'clock  at  night,  eight 
hours  after  the  stabbing,  and  proceeded  to  cleanse  the  field 
of  the  operation  and  place  the  patient  in  as  favorable  a  condi- 
tion as  my  surroundings  in  the  negro  cabin  would  admit. 
Commencing  an  incision  about  five-eighths  of  an  inch  from 
the  left  border  of  the  sternum,  I  carried  it  along  the  third 
rib  for  four  inches.  A  second  incision  was  started  at  the 
same  distance  from  the  sternum  and  carried  along  the  sixth 
rib  for  four  inches.  A  vertical  incision  along  the  anterior 
axillary  line  connected  them.  The  third,  fourth,  and  fifth 
ribs  were  cut  through  with  the  pleura.  The  musculo-osseous 
flap  was  raised,  with  the  cartilages  of  the  ribs  acting  as 
hinges.  There  was  no  blood  in  the  pleural  cavity,  but  the 
pericardium  was  enormously  distended.  I  enlarged  the  open- 
ing in  the  pericardium  to  a  distance  of  two  and  one-half  inches 
and  evacuated  about  ten  ounces  of  blood.     The  pulse  im- 


ACRDIORRIIAPIIY — CARDIOTOMY — HEART   SUTURES       165 

mediately  improved,  and  this  was  commented  upon  by  Dr. 
L.  D.  Robinson,  who  so  successfully  and  skilfully  admin- 
istered the  chloroform.  I  had  my  brother,  Dr.  S.  Hill,  pass 
his  hand  into  the  pericardial  sac  and  bring  the  heart  up- 
ward, and  at  the  same  time  steady  it  sufficiently  for  me  to 
pass  a  catgut  suture  through  the  centre  of  the  wound  in 
the  heart  and  control  the  hemorrhage.  I  cleansed  the  peri- 
cardial sac  with  a  saline  solution  and  closed  the  opening  in 
it  with  seven  interrupted  catgut  sutures.  The  pleural  cavity 
was  also  cleansed  with  a  saline  solution  and  drained  with 
iodoform  gauze.  The  musculo-osseous  flap  was  brought 
down  and  stitched  in  position.  The  operation  lasted  forty- 
five  minutes.  The  patient's  pulse,  on  reaching  his  bed,  was 
145  and  respiration  56.  I  injected  strychnine  hypodermically 
and  employed  hypodermoclysis  and  autotransfusion.  The 
following  morning,  September  15,  the  boy's  pulse  was  130 
and  temperature  102°,  and  he  was  slightly  delirious.  On 
September  16  there  was  but  slight  change  in  the  tempera- 
ture and  pulse,  though  the  delirium  was  much  worse.  On 
September  17  he  commenced  to  improve,  and  his  recovery 
has  been  uninterrupted.  I  allowed  him  to  sit  up  on  the  fif- 
teenth day.  Dr.  E.  C.  Parker,  who  assisted  me  in  the 
subsequent  management  of  the  case,  examined  the  urine  fre- 
quently, but  was  o-nly  able  once  to  find  a  trace  of  albumin. 

Conclusions — First. — Any  operation  which  reduces  the 
mortality  of  a  given  injury  from  ninety  per  cent,  to  about  six- 
ty-two per  cent.,  is  entitled  to  a  permanent  place  in  surgery, 
and  every  wound  of  the  heart  should  be  operated  on  imme- 
diately. 

Second. — Whenever  the  location  of  the  external  wound 
and  the  attending  symptoms  cause  suspicion  of  a  wound  of 
the  heart,  it  is  the  duty  of  the  surgeon  to  determine  the 
nature  of  the  injury  by  an  exploratory  operation,  as  is  recom- 
mended by  Professor  Vaughan. 

Third. — Unless  the  patient  is  unconscious,  and  corneal 


l66  THE  SURGERY  OF  THE  HEART 

reflex  abolished,  as  in  Pagenstecher's  case,  an  anaesthetic 
should  be  given,  and  preferably  chloroform.  Strugghng  is 
apt  to  produce  a  detachment  of  a  clot  and  renew  the  hemor- 
rhage, as  occurred  in  Parlavecchio's  patient. 

Fourth. — Never  probe  the  wound,  as  serious  injury  may 
be  inflicted  upon  the  myocardium. 

Fifth. — Rotter's  operation  renders  access  to  the  heart  ex- 
tremely easy,  and  should  be  generally  adopted. 

Sixth. — Steady  the  heart  before  attempting  to  suture  it 
either  by  carrying  the  hand  under  the  organ  and  lifting  it 
up,  or,  if  the  hole  is  not  large  enough,  introduce  the  little  finger, 
as  Parrozzani  did,  which  will  serve  the  double  purpose  of 
stopping  the  bleeding  and  facilitating  the  passage  of  the 
stitches. 

Seventh. — Catgut  sutures  should  be  used,  as  wounds  of 
the  heart  heal  in  a  remarkably  short  time.  The  sutures 
should  be  interrupted,  introduced  and  tied  during  diastole, 
and  not  involve  the  endocardium,  and  as  few  as  possible 
should  be  passed  commensurate  with  safety  against  leakage, 
as  they  cause  a  degeneration  of  the  muscular  fibre  with  its 
tendency  to  dilatation  and  rupture. 

Eighth. — In  cleansing  the  pericardium  it  should  be 
sponged  out,  and  no  fluid  poured  into  the  sac. 

Ninth. — It  hardly  seems  necessary  to  accentuate  the  fact 
of  the  necessity  of  perfect  cleanliness  in  these  operations 
whenever  the  urgency  of  the  case  does  not  require  instant 
intervention,  as  in  the  patients  of  Longo  and  Ninni. 

The  wound  in  the  pericardium  should  be  closed,  and 
should  symptoms  of  compression  arise,  reopen  the  wound 
and  drain  as  Rehn  did. 

By  Louis  Rassieur,  M.D.    Personal  communication. 

Edward  Spilker,  white,  single,  aged  nineteen  years,  nativ- 
ity, St.  Louis,  Mo.,  shot  himself  with  suicidal  intent  on  Sun- 
day, January  i8,   1903,  at  2.45  p.m.     "A  Christian  Scientist" 


Plate  XX. 


X  80. 


Polypus. 


(Chapter  on  Benign  Tumors.) 


CARDIORRIIAPHY— CARDIOTOMY — HEART   SUTURES       1 67 

saw  him  and  probed  the  wound  with  a  lead  pencil.  A  regu- 
lar physician  was  then  called  in.  The  latter  pronounced  the 
wound  necessarily  fatal,  and  advised  the  patient's  transfer 
to  the  St.  Louis  City  Hospital. 

When  he  arrived,  at  3.45  p.  m.,  his  pulse  was  bad,  his 
abdomen  board-like.  A  powder-burned  pistol  wound  was  in 
the  fourth  interspace,  just  below  and  internal  to  the  left  nip- 
ple. The  chest  showed,  on  physical  examination,  signs  of  a 
slight  hsemothorax. 

There  were  none  of  the  many  symptoms  so  clearly  classi- 
fied by  the  various  writers  which  are  pathognomonic  of  gun- 
shot wound  of  the  heart.  The  patient  looked  pale  and  was 
very  indisposed. 

The  senior  physician,  who  first  saw  the  case,  in  fact,  re- 
ported it  to  me  as  one  of  gunshot  wound  of  the  chest,  with 
the  bullet  ranging  down  toward  the  peritoneal  cavity,  not  at 
all  divining  the  fact  that  the  bullet  had  struck  not  only  the 
heart,  but  the  left  lung  also. 

I  ordered  the  patient  prepared  for  operation.  The 
preparation,  et  csetera,  took  about  two  hours.  During  this 
time  he  bled  about  a  pint  and  a  half  from  the  gunshot 
wound. 

When  the  patient  was  placed  on  the  table  for  operation, 
he  presented  a  different  picture.  He  was  now  well-nigh  de- 
pleted, almost  indifferent,  and  covered  with  profuse  perspira- 
tion. He  was  anaesthetized  with  chloroform.  The  operation 
began  at  5.45  p.  m. 

Operation. — An  incision  three  inches  long,  parallel  to  the 
left  papillary  line,  was  made,  extending  through  the  gunshot 
wound.  One  inch  of  the  fourth  and  fifth  ribs  was  resected, 
one-half  inch  of  the  cartilaginous  and  one-half  Inch  of  the 
bony  portion  of  the  respective  ribs.  The  intercostal  vessels 
were  secured  by  silk  ligatures.  The  chest  was  now  full  of 
blood.  I  turned  the  patient  on  his  belly  to  let  the  blood  run 
out  of  the  chest.     Then  I  turned  him  on  his  back,  and  found 


r68  THE  SURGERY  OF  THE  HEART 

on  examination  a  hole  in  the  pericardium,  which  was  also 
powder-stained. 

I  enlarged  the  hole  two  inches.  The  heart-sac  was 
full  of  blood.  I  mopped  out  the  heart-sac  with  sterile  gauze, 
and  with  the  left  hand  drew  the  heart  forward,  grasping  the 
heart  at  the  apex.  There  was  a  ragged  laceration  of  the  wall 
of  the  left  ventricle  midway  between  the  base  and  the  apex. 
The  laceration  bled  freely  and  was  half  an  inch  wide,  three- 
eighths  of  an  inch  deep,  and  an  inch  and  a  half  long.  Three 
silk  sutures,  of  medium-sized  silk,  were  introduced  into  the 
heart  muscle.  The  approximation  was  ideal.  The  haemor- 
rhage from  the  heart  muscle  ceased. 

On  further  examination  of  the  pericardium,  the  wound 
of  exit  was  found  in  the  bottom  of  the  sac.  I  washed  the 
sac  with  physiological  saline  solution.  I  then  cut  out  the 
burned  portion  of  the  sac  and  now  approximated  the  sac  in- 
cision with  eight  medium-sized  silk  sutures,  thus  using  no 
drainage  in  the  pericardium. 

I  now  drew  forth  the  lower  lobe  of  the  left  lung.  The 
lower  lobe  had  been  perforated  by  the  bullet  and  was  bleed- 
ing freely.  About  a  square  inch  and  a  half  of  the  lower  lobe 
was  infiltrated  with  extravasated  blood.  I  raised  this  portion 
of  the  lung,  and  then  tied  around  it  a  silk  ligature  of  the 
heaviest  silk.  Thus  the  lower  portion  of  the  lower  left  lobe 
was  ligated  en  masse;  treated  as  if  it  were  but  a  single  vessel. 
The  ligature  was  drawn  very  tight,  crushing  the  lung  tissue. 
The  part  beyond  the  ligature  was  cut  away.  In  this  way 
the  bleeding  of  the  lung  was  disposed  of  in  three-quarters  of 
a  minute. 

During  the  operation  I  had  the  median  flap  of  the  chest 
wound  raised  with  a  retractor.  While  sewing  the  heart  I 
held  it  with  my  left  hand  against  the  median  side  of  the 
chest,  and  introduced  my  silk  sutures  w^ith  a  gut  needle.  I 
used  a  Halsted  artery  forceps  as  a  needle  holder.  I  now 
turned  the  patient  on  his  belly  to  rid  the  chest  of  the  blood. 


CARDIORRHAPHY — CARDIOTOMY — HEART  SUTURES   169 

Now  I  rolled  him  on  his  back.  I  introduced  a  single  strand 
of  gauze  into  the  left  pleural  cavity  as  a  drain.  The  gauze 
in  the  mouth  of  the  pleural  wound  had  an  additional  motive, 
in  that  it  kept  the  mouth  of  the  wound  open  and  permitted 
filtered  air  to  rush  into  the  pleural  cavity,  thus  forming  an 
air  cushion  or  splint  about  the  left  lung,  preventing  the  ex- 
pansion of  the  lung  and  the  occurrence  of  pneumonia. 

The  bullet  was  somewhere  in  the  muscles  of  the  back. 
The  pectoral  muscles  were  approximated  with  medium-sized 
silk,  the  skin  with  silkworm  gut.  The  operation  ended  at  6.45 
P.M.;  duration,  fifty-five  minutes;  anaesthesia  with  chloro- 
form (Squibb's). 

No  stimulants  were  given  save  a  hypodermoclysis  of 
physiological  saline  solution,  250  c.c,  just  before  the  opera- 
tion. 

Post-Operative  Course. — When  the  patient  was  put  to  bed 
his  chart  was  99.2°  F. ;  respiration,  28;  pulse,  100.  He  com- 
plained of  severe  incessant  pain  over  the  region  of  the  heart. 
The  temperature,  respiration,  and  pulse  grew  rapidly  higher. 
The  highest  point  was  reached  the  next  morning  at  3  a.m. 
(January  19,  1903).  Temperature,  103.4°  F. ;  respiration,  36; 
pulse,  152.  Then  it  receded.  At  9  p.  m.^  temperature,  100.2°  ; 
respiration,  38;  pulse,  132. 

January  20. — 102.8°  ;  respiration,  30;  pulse,  128.  Severe 
heart  pain  continued.  At  6  p.  m.  the  patient  got  up  and  walked 
sixty  feet,  and  went  to  bed  again.  His  walk  did  not  harm  him. 
He  wished  for  a  great  deal  of  nourishment.  He  was  given  four 
ounces  of  water,  milk,  or  beef-tea  hourly  if  awake.  (For 
twenty-four  hours  after  the  operation  he  was  fed  entirely  per 
rectum.) 

January  21. — Temperature,  101°;  respiration,  36;  pulse, 
106.  Resting  easier.  Drain  removed  from  the  pleural  cavity, 
none  returned.  A  slight  amount  of  bloody  fluid  (three 
ounces)  came  from  the  chest  on  turning  the  patient  on  his  ab- 
domen. 


I/O  THE   SURGERY   OF   THE   HEART 

Jwmary  22. — Temperature  100°  ;  respiration,  33 ;  pulse, 
106.  Continues  in  fine  condition.  A  slight  systolic  murmur 
heard  best  over  the  base  of  the  heart;  no  physical  signs  of 
pneumonia. 

January  2^. — Temperature  99.4°;  respiration,  36;  pulse, 
106.     Continues  in  fine  condition. 

Patient  is  dressed  once  every  two  days.  He  sleeps  well. 
He  receives  five  saline  enemata  every  twenty-four  hours  and 
an  occasional  hypodermic  of  morphine  sulphate,  grain  one- 
sixth.  Up  to  the  present  time  he  has  received  nine-sixths 
of  a  grain  of  morphine  sulphate.  Absolutely  no  other  form 
of  medicines  and  no  other  stim.ulants,  not  even  alcoholic,  have 
been  resorted  to.     The  morphine  was  the  only  drug  used. 

(This  is  the  third  case  under  my  observation.  I  saw  Dr. 
Neitert's  two  cases  daily.) 

Analysis  of  Fifty-six  Cases  of  Heart  Suture 

Character  of  the  Wound. — The  majority  of  the  wounds 
were  single  and  non-penetrating.  However  the  percentage  of 
recoveries  from  penetrating  wounds  that  had  been  sutured 
was  quite  as  large  as  from  those  of  non-penetrating  wounds. 

Probably  two-thirds  of  the  wounds  of  the  heart  that  had 
been  sutured  had  been  produced  by  dagger-like  instruments; 
some  accidental,  some  with  suicidal,  and  still  more  with  mur- 
derous intent. 

The  greater  number  of  subjects  of  heart  injuries  operated 
upon,  and  the  surgeons  operating  upon  them,  have  been 
Italians.  This  probably  accounts  for  the  frequency  of 
wounds,  stiletto-like  in  character.  The  mortality  is  greater 
in  gunshot  wounds. 

In  one  case  operated  upon  death  was  due  to  the  failure 
of  the  operator  to  close  the  endocardial  opening  with  the 
external  opening  in  the  heart.  This  is  one  of  the  greatest 
dangers,  and  should,  therefore,  be  carefully  guarded  against. 


CARDIORRHAPIIY—CARDIOTOMY— HEART   SUTURES       17I 

AnccstJictic. — Surgical  anaesthesia  by  any  means  is  not  al- 
ways necessary  to  suture  the  heart.  Many  such  operations 
have  been  done  without  it.  The  greatest  judgment  should 
be  exercised  in  the  use  of  chloroform,  ether,  or  nitrous  oxide. 
Both  ether  and  chloroform  have  been  used,  and,  again,  the 
operation  has  been  frequently  done  without  their  use,  some- 
times while  the  patient  was  unconscious  and  sometimes  while 
he  was  conscious. 

Many  of  these  injuries  will  not  admit  of  sufificient  time  to 
produce  artificial  unconsciousness,  others  will,  however, 
especially  in  non-penetrating  wounds  of  the  heart,  a  condi- 
tion that  cannot  be  determined  without  opening  the  peri- 
cardium. 

External  Location  of  the  Wound. — This  may  be  at  any 
point  upon  the  chest,  abdomen,  or  neck,  in  any  of  the  soft 
or  bony  tissues.  About  eighty-five  per  cent  of  those  operated 
upon  have  been  on  the  left  chest,  ranging  from  the  axillary 
line  to  the  anterior  median  line,  from  the  third  to  the  seventh 
intercostal  space.  The  fourth  and  fifth  intercostal  spaces  are 
the  most  frequent  locations  of  entrance. 

Time  of  Operation  After  Injury. — This  depends  upon  en- 
vironments and  the  aggressiveness  of  the  attendants  in  whose 
hands  the  life  of  the  patient  is  intrusted.  In  two  or  three 
instances  the  operation  was  done  immediately,  in  fifteen  to 
thirty  minutes,  and  in  one  as  late  as  twenty-four  hours 
after  the  injury. 

The  wounds  have  been  non-penetrating  in  the  majority 
of  cases  operated  upon  late.  In  a  few  there  was  a  very  super- 
ficial non-penetrating  wound  with  severance  of  one  or  both 
of  the  coronary  vessels,  vein  and  artery. 

Accidents  During  Operation. — In  one  a  branch  of  the  cor- 
onary artery  was  severed,  probably  with  the  needle  while 
suturing.  In  another  an  injured  sasptum  was  overlooked,  and 
in  still  another  a  perforation  of  the  ventricle,  posterior,  was 
not  closed  with  the  external  opening  in  the  heart. 


172  THE   SURGERY   OF   THE   HEART 

« 

Kinds  of  Suture. — Silk  and  catgut  have  been  the  only 
material  employed.  Interrupted  silk  sutures  have  been  most 
frequently  employed,  from  one  to  seven  in  number  in  each 
individual  case.  Continuous  sutures  were  used  in  but  two 
or  three  cases.  Catgut  has  been  very  infrequently  employed. 
In  one  case  in  particular  both  interrupted  and  continuous 
sutures  of  this  material  were  employed,  with  recovery  of  the 
patient. 

Deaths  and  Duration  of  Life  After  Operation. — Several 
have  expired  on  the  table  during  or  at  the  completion  of  the 
operation;  others  from  fifteen  minutes  to  several  days  after 
the  operation.  Unconsciousness  prevailed  in  a  few  at  the 
time  of  operation,  so  that  anaesthetics  w^ere  not  required  for  the 
operation. 

Causes  of  Death. — Exhaustion  from  haemorrhage  or  in- 
fection is  most  common.  Hemorrhage  is  the  more  common. 
It  may  result  in  instant  death  or  it  may  be  slow  and  gradual. 
Death  may  occur  from  loss  of  blood  resulting  from  a  pene- 
trating wound  of  the  heart,  its  great  vessels,  the  mammary,  in- 
tercostal, pulmonary,  or  coronary  arteries,  one  or  all,  singly 
or  combined. 

Empyema,  pleurisy,  bronchopneumonia,  carditis,  and  peri- 
carditis each  has  contributed  to  the  causation  of  death  in 
this  class  of  cases. 

Mortality. — Fifty-six  operations:  twenty  recoveries.. 

Age  Most  Favorable  for  Reeovcry. — From  twenty  to  for- 
ty-five the  blood-pressure  is  comparatively  high,  and  the 
stress  of  blood-pressure  on  the  arterial  walls  causes  an  in- 
crease in  diameter  of  the  large  arteries.  There  is  also  a 
progressive  increase  in  the  size  of  the  heart,  year  by  year, 
at  a  nearly  uniform  rate.  But  after  forty-five,  although  the 
arteries  continue  to  increase  in  size,  there  is  a  fall  in  the  blood- 
pressure.  At  the  same  time,  almost  suddenly,  the  heart  be- 
gins to  diminish  in  size.  The  widening  of  the  arterial  trunks 
and  fall  of  blood-pressure,  the  reduction  of  mechanical  stress 


Plate  XXI. 


rfe^.. 


X  105. 

Sarcoma,    (Giant  Cell). 


X  3G0. 

Sarcom.v,  (Spindle  Cell), 


(Chapter  on  Malignant  Tnmors.) 


CARDIORRHAPHY — CARDIOTOMY— HEART  SUTURES   I  73 

from  bodily  relaxation,  the  loss  of  tone  in  the  vasomotor 
mechanism  of  the  splanchnic  area,  are  all  factors  in  produc- 
ing this  diminution  in  the  size  of  the  heart.  Any  chronic 
disease  which  usually  afflicts  men  at  this  age  may  perhaps 
have  some  influence  in  this,  too.  There  is  also  a  change  in 
the  quality  of  the  blood.  It  becomes  more  venous.  At  sixty- 
five  a  large  portion  of  the  capillary  network  becomes  obso- 
lete because  of  lowered  metabolic  and  functional  energy  of 
the  tissues  caused  by  this  decline  of  circulatory  energy  and 
the  effects  of  age  on  the  cell  contents  of  the  body. 

These  changes  increase  the  peripheral  resistance,  which 
causes  a  rise  in  the  blood-pressure.  This  in  turn  produces  an 
increase  in  the  size  of  the  heart,  so  that  the  heart  at  fifty- 
five  is  as  large  as  it  was  at  forty-five.  At  the  same  time  the 
haemoglobin  value  of  the  blood  becomes  higher.  There  is 
no  reason  why  the  heart  should  not  remain  structurally  sound 
until  the  most  advanced  years  of  life;  that  is,  there  is  no 
physiological  reason  for  structural  degeneration  unless  there 
is  some  disease  present;  hence  all  cardiac  and  vascular  dam- 
age that  occurs  in  the  second  half  of  life  must  be  produced 
by  physical  stress  caused  by  sudden  and  violent  exertions 
or  from  some  severe  laborious  occupation.  Care  must  be 
taken  to  see  that  men  of  middle  age  who  are  advised  to  take 
physical  exercise  do  not  overdo  it. 

Depressing  emotions  originating  in  worry,  anxiety,  etc., 
no  doubt  also  are  factors  in  producing  cardiac  troubles.  Then, 
again,  nervous  depressions  which  may  cause  the  foregoing 
are  due  to  disease,  such  as  gout,  influenza,  malaria,  tubercu- 
losis, and  syphilis. 

Overwork,  worry,  and  nervous  troubles  are  often  held 
responsible  for  causing  cardiac  failure,  when  in  fact  the  true 
cause  is  alcohol.  All  disturbances  of  metabolism  in  middle 
life  are  apt  to  cause  heart  troubles,  especially  in  the  so-called 
middle  and  higher  classes  of  society. 


174  THE  SURGERY  OF  THE  HEART 


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178  THE  SURGERY  OF  THE  HEART 

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McLaughlin,  1903,  Personal  communication. 

Rassieur,  1903,  Personal  communication. 


CHAPTER  VIII 
CARDIAC    ANEURYSM 

Aneurysm  of  the  heart  may  involve  any  portion,  or  the 
whole,  of  the  cardiac  wall,  the  left  ventricle  and  upper  portion 
of  the  interventricular  sseptum  being  most  frequently  involved. 
The  causes  are  those  which  produce  aneurysm  in  any  part 
of  the  arterial  system.  Heart  strain  and  syphilis  are  the  most 
frequent,  but  in  some  cases  fatty  degeneration  may  be  a 
prominent  causative  factor. 

There  are  no  definite  symptoms  by  which  cardiac  aneurysm 
may  be  recognized,  nor  is  there  any  curative  treatment.  Lit- 
tle indeed  can  be  accomplished  in  the  way  of  palliation. 

Historical  (1843-1903). — In  1843  Craig  published  his  ob- 
servations and  reported  cases,  illustrating  the  false  consecutive 
aneurysm  of  the  heart.  Billingham  (1850)  reported  a  case  of 
aneurysm  in  the  apex  of  the  left  ventricle,  followed  by  pericar- 
ditis. Bristowe  (1853),  Elliott  (1857),  Habershon  (1862), 
Arnott  (1868)  and  Girdlestone  (1869),  all  report  cases  of  an- 
eurysm of  the  left  ventricle.  In  the  case  of  Arnott  there  was 
partial  ossification  of  the  heart-wall,  winding  around  the  root  of 
the  aorta. 

Gore  (1872)  reported  an  aneurysmal  tumor  of  the  aorta 

forming  in  the  walls  of  the  left  ventricle.     Barlowe  (1875) 

mentions  an  aneurysm  in  the  base  of  the  left  ventricle,  and 

Janeway  (1875)  ^  double  one  in  the  same  cavity.     Hughes 

(1883),   Allen   (1883),   Handford   (1885),   Haig   (1885),  and 

Sharkey  (1885),  each  reported  cases.     In  Sharkey's  case  there 

was  also  an  aneurysm  of  the  aorta. 

179 


l80  THE  SURGERY  OF  THE  HEART 

In  1888  Yonge  reported  a  case  simulating  aneurysm  of 
the  descending  aorta.  In  1898  Sangree  had  a  case  of 
aneurysm  of  the  left  ventricle,  and  Burgess  in  the  same  year, 
one  terminating  in  sudden  death. 

Georgiades  (1894)  mentions  a  case  in  a  man  sixty-five 
years  of  age,  in  whom  there  was  found  an  aneurysm  about 
the  size  of  a  walnut,  at  the  apex  of  the  left  ventricle. 

Hewett  (1849)  reported  an  aneurysmal  dilatation  of  the 
left  auricle,  with  thickening  and  contracting  of  the  left  auriculo- 
ventricular  opening.  Dawes  (1875)  reported  a  case  of 
aneurysm  of  the  base  of  the  pulmonary  artery.  Irwine  (1878) 
mentioned  a  case  of  displacement  of  the  aortic  valve  by  an 
aneurysm  in  the  ventricular  sseptum. 

Newcomb  (1884)  reported  a  case  in  which  all  of  the  signs 
and  symptoms  of  aortic  aneurysm  were  simulated  by  an 
enormously  dilated  heart. 

Williams  (1890)  reported  an  aneurysm  of  the  pulmonary 
artery.  In  1892  Hebb  gives  a  case  of  atheroma  of  the  pul- 
monary artery,  and  Kidd  an  emboHc  aneurysm  of  the  pul- 
monary artery  with  aortitis,  pulmonary  endarteritis,  and 
patent  ductus  arteriosus. 

In  1895  GafTon  records  a  case  of  aneurysm  of  the  coronary 
artery  due  to  its  obliteration,  and  Claude  an  aneurysm  in  a 
case  of  obliteration  of  the  anterior  coronary  artery. 

Turney  (1896)  reports  a  case  of  intra-pericardial  aneurysm 
of  the  aorta.  Callett  and  Steele  ( 1898)  report  a  case  of  aneur- 
ysm of  the  right  pulmonary  aortic  sinus  of  Valsalva,  with 
rupture. 

Salvilli  (1885)  reports  a  case  of  aneurysm  of  the  inter- 
ventricular saeptum,  and  Taylor  (1886),  Maguire  (1886).  Pert 
(1889),  Northup  (1888),  and  Klein  (1889),  each  mention  cases 
of  like  character. 


Plate    XXII. 


JS(L 
X  270. 


Sarcoma,  (Small  Round  Cell), 


(Chapter  on  Malignant  Tumors.) 


CARDIAC  ANEURYSM  l8l 

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Dawse,  T.  S.,  Tr.  Path.  Soc,  London,  1875,  XXVI,  28. 
Janeway,  New  York  Med.  Journal,  1875,  XXI,  54. 
Irvine,  J.  P.,  Tr.  Path.  Soc,  London,  1878,  XXIX,  47-49- 
Bell,  Lancet,  London,  1878,  I,  y2^. 
Talamon,  Bull.  Soc.  Anat.,  1879. 
EvART,  Path.  Society,  London,  1880. 
Peabody,  New  York  Aledical  Society,  1881. 
Ingals,  Aneurysm  of  the  Heart.  Med.  Rec,  New  York,  1881, 

XX,  313-315- 

Laurand,  G.,  Anevrysme,  valvule  mitrale,  embolic  de  la  cru- 

rale.     Bidl.  Soc.  Anat.,  Paris,  1881,  LVI,  425-426. 
MacLeod,  N.,  A  movable  clot  in  the  rigfht  auricle.     Edinb. 

Med.  Jour.,  1882-83,  XX VIII,  696. 
Dulaceska,  G.,  Aneurysma  cordis  partialis  chronica.     Gyog- 

yasj^at,  Budapest,  1883,  XXIII,  145-149. 
Legg,  Wickham,  Bradshawe  lecture,  1883. 
Turner,  Path.  Society,  London,  1883. 
Balzer,  F.,  Anevrysme  miliares  du  pericarde  chez  un  syphil- 

itique.     Arch.  d.  Pliys.  Norm,  et  Path.,  Paris,  1883,  II, 

93-95- 

Ferguson,  Aneurysmal  dilatation  of  the  heart  and  mitral  ste- 
nosis, fibroid  induration.  Med.  Rec,  New  York,  1883, 
XXIV,  75. 

Schmidt,  H.  D.,  The  pathological  anatomy  of  an  aneurysm  of 
the  heart.  New  Orleans  Med.  and  Surg.  Jour.,  1883-84, 
XI,  333-342  ;  I  pi.  ^ 

Durand,  p.  E.,  Des  anevrysmes  des  sinus  de  Valsalva  a  deve- 
loppement  intra-cardiaque.     Lyon,  1883. 

Hughes,  W.  E.,  Philadelphia  Med.  Times,   1883-84,  XIV, 

439-838. 
FouLis,  J.,  On  a  case  of  patent  ductus  arteriosus  with  aneurysm 
of  the  pulmonary  artery.     Tr.   Med.   Chir.   Soc,   Edin- 
burgh, 1883-84,  U.S.,  Ill,  156-175. 


CARDIAC   ANEURYSM  183 

Senise,  T.,  Un  case  di  dilatazione  aneurismatica  del  ctiore. 

Ann.  Clin.  d.  osp.  Incur.,  Napoli,  1883,  VIII,  136-143. 
Jacquet,  Anevrysme  du  coeur,  foyer  de  ramollissement  em- 

bolique  de  la   protuberance.     Prog.  Med.,  Paris,   1884, 

XII,  172. 
KiDD,  P.,  Cardiac  aneurysm.     Brit.  Med.  Jour.,  London,  1884, 

II,  909. 
Legg,  J.  W.,  Some  account  of  cardiac  aneurysms.      London, 

1884. 
Newcomb,  J.  E.,  Med.  Rec.,  New  York,  1884,  XXVI,  263. 
KiDD,  P.,   Cardiac  aneurysm.     Brit.  Med.  Journal,  London, 

1884,  II,  909. 

Richet,  Anevrysme  du  coeur  et  abces  thoracique,     Semaine 

Med.,  Paris,  1884,  IV,  517. 
Handford^  H.,  Lancet,  London,  1885,  I,  198. 
Brinkman,  a..  Valvular  aneurysm.     New  York  Med.  Jour., 

1885,  XIII,  455- 

Butler,  G.  R.,  Aortic  stenosis;  aneurysm  of  the  aortic  valves; 

mitral  stenosis  and  regurg.     New  York,  1885,  XIII,  415. 

Anevrysme  medial  double  des  parois  du  coeur.     Jour,  de 

Med.,  Bordeaux,  1885-86,  XV,  2. 
Leyder,  E.,  Uber  einen  fall  von  Herzaneurysme.    Deut.  Med. 

Woche.,  1885,  XI,  115. 
Haig^  Lancet,  London,  1885,  II,  1045. 
Salvioli,  Salute  italia  Med.,  Savona,  1885,  XIX,  368-370. 
KiDD,  P.,  Four  cases  of  cardiac  aneurysm.     Tr.  Path.  Soc., 

London,  1884-85,  XXXVI,  127-133. 
Sharkey,  S.  J.,  Tr.  Path.  Soc,  London,  1884-85,  133-135. 
Taylor,  F.,  British  Med.  Journal,  1886,  I,  447. 
PocHMANN^  E.,  Aneurysma  cordis  ventric.  sin  circumscriptum 

verum  plotzlicher  tod  durch  berstung  und  bluterguss  in 

das  perikardium.  Wien.  Med.  Prcsse,  1886,  XXVII,  1403. 
Rendu,  H.,  Note  sur  un  cas  d'anevrysme  partiel  du  coeur  avec 

des  remarques  sur  la  pathogenic  et  la  symptomatologie  de 

cette  lesion.     Bull,  et  Mem.  Sac.  d.  Hop.,  Paris,  1887, 

IV,  455-467. 


l84  THE   SURGERY   OF   THE   HEART 

Chavanis,   Observation   d'anevrysme  du   sinus   de   Valsalva 

ouvert  dans  I'artere  pulmonaire.     Loure  Med.,  St.   Eti- 

enne,  1888,  VII,  1-5. 
Maguire,    R.,    Tr.    Path.    Soc,    London    (1886-87),    1887, 

XXXVIII,  100-102. 
Money,  A.,  Aneurysm  of  the  heart,  cerebral  tumor,  idiocy. 

Ibid,  97-99. 
MooRE,  N.,  Aneurysm  of  sinus  of  Valsalva.     Ibid,  100. 
YoNGE,  G.  H.,  Med.  Press  and  Circ,  London,  1888,  XLV,  6.^8. 
Marchisio^  C,  Esteso  aneurisma  parziale  cronico  del  cuore 

per  sclerosi  della  arterie  coronaire.     Rev.  Clin.,  Milano, 

1888,  XXVII,  594-602. 
Fischer,  G.,  Uber  einen  fall  von  aneurysma  sinus  Valsalva. 

Erlangen,  1889. 
Mader,  J.,  Bertsung  eines  Herzaneurysma  des  in  folga  athero- 

matose  einer  Kranzarterie  enstand  primare  schumpfiniern 

tod.     Ber.  k  k  Krankenanst.     Rudolph-Siftung  in  Wien 

(1887),  1888,  323. 
Pert,  Lancet,  London,  1889,  I,  791. 
NoRTHRUP  W.  P.,  Proc.  New  York  Path.  Soc.  (1888),  1889, 

43- 
Klein,  G.,  Berlin,  1889,  CXVIII,  57-69;  i  pi. 
Fischer,  G.,  Uber  einen  fall  von  aneurysma  sinus  Valsalva. 

Erlangen,  1889. 
Williams,  C.  B.,  Weekly  Med.  Rev.,  St.  Louis,  1890,  XXI, 

221-225. 
BoissoN   G.,   Anevrysme   du   cceur,    ramollissement   cerebral 

arterite  syphilitique  probable  de  I'encephale  et  des  coro- 

naires.     Bull.  Soc.  Anat.,  Paris,  1889,  LXIV,  534-538. 
De  Grandmaison,  Anevrysme  du  cceur.    Ibid,  626. 
Lop,  Anevrysme  de  la  pointe  du  coeur.    Marseille  Med.,  1890, 

XXVII,  566. 
Von  Krayurcki,  C.,  Das  Septum  membraneum  ventriculorum 

cordis  sein  verhaltniss  sum  sinus  Valsalva  dexter  aortae 

und  die  aneurysmatischen   veranderungen  beider.     Beit. 

z.  Path.  Anat.  und  Allg.  Path.  Jena,  465-484. 


CARDIAC   ANEURYSM  185 

Marckwald,  E.,  Zur  Kenntniss  des  chronischen  Herzaneur- 
ysms.     Halle,  1891. 

BossARD,  Dilatation  anevrysmale  du  ventricule  gauche  et  per- 
foration de  I'estomac  consecutive  a  une  lesion  cardiaque ; 
mort  par  peritonite  suraigue.  Med.  Poitiers,  1891,  V, 
265-271. 

Mackenzie  and  Williams,  A  case  of  aneurysm  of  the  heart 
with  symptoms  of  angina  pectoris  during  life.  Med. 
Chron.,  Manchester,  1891-92,  XV,  302-305. 

Mackenzie,  H.  W.  S.,  Aneurysm  of  the  heart,  contracted 
granular  kidneys.  St.  Thomas  Hospt.  reports,  London, 
1890-91,  XX,  337. 

ViDAL,  Observation  d'anevrysme  intra-cardiaque ;  communica- 
tion du  ventricule  gauche  avec  I'oreillette  droite.  Loire 
Med.,  St.  Etienne,  1892,  XI,  121,  126. 

Omerod,  J.  A.,  Aneurysm  of  Heart.  Tr.  Path.  Soc,  London, 
1890-91,  XLH,  60. 

Lop,  p.  a.,  Contribution  a  I'etude  des  anevrysmes  du  cceur. 
Rev.  de  Med.,  Paris,  1892,  XH,  558-566. 

Cuffer,   Des  anevrysmes  du   coeur.     Semaine  Med.,   Paris, 

1893,  xni,  43. 

Hebb,  R.  G.,  Tr.  Path.  Soc,  London,  1892-93,  XLIV,  45-47. 

KiDD,  P.,  Tr.  Path.  Soc,  London,  1892-93,  XLIV,  47. 

Openchovsky,  T.  M.,  Rare  case  of  aneurysm  of  sinus  of  Val- 
salva followed  by  disease  of  valves  of  heart.  Vratch,  St. 
Petersburg,  1894,  XV,  705. 

Georgiades,  Zur  Kenntniss  der  Herz-aneurysmen.  Munchen, 
1894. 

Pettus,  W.  J.,  Bradycardia  caused  by  aneurysm  of  one  of  the 
sinuses  of  Valsalva.     New  York  Med.  Jour.,  1894,  LX, 

551- 

Vasiljeff,  N.  T.,  Kazuist  aneurysma  sinus  Valsalva.  Sovrem 
Klin.,  St.  Petersburg,  1894,  II,  No.  10,  35. 

Von  Openchowski,  T.,  Uber  einen  seltenen  fall  von  aneurys- 
ma sinus  Valsalva  mit  nachfolgender  functioneller  stehung 
der  herzklappen.  Bed.  Klin.  Woch.,  1895,  XXXII,  140- 
142. 


1 86  SURGERY    OF   THE   HEART 

Claude,  H.,  Bull.  Soc.  Anat.  dc  Paris,  1895,  LXX,  433. 
GuFFOX,  v.,  Bull  Soc.  Anat.  dc  Paris,  1895,  LXX,  620. 
Embley,  E.  H.,  a  case  of  aneurysm  of  the  heart  and  a  probable 

diagnostic  sign  of  such  condition.     Australas.  Med.  Jour., 

Melbourne,  1895,  XVII,  361. 
GouGET,    A.,   Un   nouYcau   cas   d'anevrysme    du    cceur    aYCC 

nephrite  d'origine  cardiaque.     Ibid,  i^y-i^^. 
Marie  et  Rabe,  Un  cas  d'aneYrysme  du  coeur.    Ibid,  157. 
Verbitski,  M.  K.,  a  proof  of  a  case  of  aneurysm  of  the  heart. 

Trudi.  Obsh.  Russk.     Vratch.,  St.  Petersburg,  1894-95. 

LXI,  70-74. 
Da\is,  a.   N.,  a  case  of  aneurysm  of  the  heart,  necropsy. 

Lancet,  London,  1896,  II,  381. 
CoxTi,  P.,  Un  caso  di  aneurisma  del  setto  Yentricolare.     Atti 

d.  Assn.  Med.  Lomb.,  Milano,  1896,  291-318. 
Shat,  T.  S.,  a  case  of  aneurysm  of  the  heart.     Brit.  Med. 

Jour.,  London,  1897,  I,  1146. 
]Mader,  J.,  Herzaneurysme  mit  relatiYcr  insufficientia  vahailae 

bicuspid   dis.  tod.     Jahrb.   d.    Wien  K.  K.  Krankenant, 

1895,  Leipsic,  1897,  IV,  pt.  II,  250. 
Parisot  et  Spillman,  Qideme  pulmonaire  et  auevrysme  du 

coeur.     Rev.  de  Med.  de  Vest,  Nancy,  1897,  XXIX,  391- 

39^5. 
Hare,  H.  A.,  A  case  of  suspected  cardiac  aneurysm.     Med. 

Rcc.,  New  York,  1897,  LXXXI,  728. 
Sailer,  J.,  Heart  with  two  ventricular  aneurysms.    Proc.  Path. 

Soc,  Philadelphia,  1897,  I,  1-9. 
BuRGOSS,  A.,  Des  anevrysmes  dissequants  du  coeur.      Nort. 

Med.  Ark.,  Stockholm,  1897,  VIII,  Heft  5,  No.  26,  1-65 ; 

2  pi. 
Gardner,  W.  J.,  Chronic  aortic  endocarditis  associated  with  a 

small  aneurysm  which  bulged  into  the  infundibulum  of  the 

right  ventricle.     Glasgow  Med.  Jour.,  1898,  XLIX,  195, 

198. 
Martin,   E.,  Anevrysme  de  I'artere  de  la   valvule   mitrale. 

Lyon  Med.,  1898,  LXXXVII,  267,  269. 


CARDIAC   ANEURYSM  18/ 

TuRNEY,  H.  G.,  Tr.  Path.  Soc,  Lond.,   1896-97,  XLVIII, 

56. 
Caccloglu  C,  Aneurysm  of  the  heart.     Protok.  Zasand  Obsh. 

Morsk.  Vrach.  V.  Kromstadt,  1896-97,  XXXV,  83-88. 
Lemeignen,  Siir  iin  cas  d'anevrysme  cardiaque.    Ga^'.  Med.  de 

Nantes,  1897-98,  XVI,  166. 
Sangree,  E.  B.,  Journal  of  the  Am.  Med.  Assn.,  1898,  XXX, 

1401. 
Bernard,  H.,  Anevrysme  du  coeur.      Bull.  Soc.  Anat.,  Paris, 

1898,  LXXXIII,  399. 
Torregiam,  Aneurisma  multiple  delle  crecchiette.     Gior.  d.  r. 

Soc.  Med.  Acad.  Ital,  Torino,  1898,  XLVII,  841. 
Callett    et    Steele,   Tr.    Path.    Soc,    Philadelphia,    1898, 

XVIII,  203-211. 
Drasche,  a.,  Uber  aneurysmes  an  der  herzklapper.      Wien. 

Klin.  Woch.,  1898,  XI,  1017-1024. 
Burgess,  J.  J.,  Tr.  Royal  Acad.  Med.,  Ireland,  1898,  XVI, 

324-326. 
Levashoff    I.  M.,  Sur  I'anevrysme  chronique  du  ventricule 

gauche  du  coeur  ext.  397.     Russk.  Arch.  Patol.  Clin.  Med. 

I  Vak.,  St.  Petersburg,  1898,  VI,  261-361. 
Drasche,  Philadelphia  Med.  Journal,  May  20,  1899,  speaks 

of  three  cases,  a  woman  66,  inflammatory  in  character,  a 

boy  19,  result  of  endocarditis,  and  the  third  due  to  tighten- 
ing of  cordse  tendinas. 
Cruveilhier,  Anat.  Path.,  liv.,  XXI. 
Schroetter,  Ziemssen's  Handbuch,  Bd.  VI. 
Reynaud,  Arch.  Anevrysme  in  Nouveau  Diet,  de  Med. 
Morgagni,  Epist.  XVII. 
Oppel,  W.  a.  v.,  Beitrag  zur  frage  der  Fremdkorper  im  her- 

zen,  Archives,  f.,  Klinische  Chirurgie,  Berlin,  1901,  Ixiii, 

87-115,  I  taf. 
KoHLEPP,  Tod,  in  folge  verletzung  einer  herzvene,  Mitthcil- 

ung  d.  ver.  bad.  Thierdrt:;e,  Karlsruhe,  1901,  i.  44-45. 
BouREAu,  Maurice,  Le  massage  du  coeur  mis  a  nu,  Revue  de 

Chirurgie,  Paris,  1902,  xxvi,  526-532. 


l88  THE  SURGERY  OF  THE  HEART 

Stubbe,  Paul,  Ein  fall  einer  eigenartigen  herzverletzung  in- 
augural dissertation,  Erlangen,  1902,  September,  No.  26. 

Wetzel,  Uber  verletzungen  der  brust  speziell  des  herzens. 
Miinchcn  Medicinische  Wochenschrift,  1902,  xlix,  1260- 
1264. 

Wagener,  Oskar,  Ueber  die  methoden  der  freilegung  des  her- 
zens zur  vornahme  der  nahtnach  verletzungen  inaugural 
dissertation,  Kiel,  1902,  Juni  u  Juli,  No.  yy. 


CHAPTER  IX 
FOREIGN    BODIES 

It  has  been  shown  that  many  kinds  and  sizes  of  foreign 
bodies  may  form  within,  or  enter  from  without  the  heart, 
and  yet  hfe  be  maintained  indefinitely.  Foreign  bodies  in  the 
hearts  of  bipeds  are  usually  found  in  the  floor  of  one  of  the 
two  ventricles.  The  heart  of  quadrupeds  is  in  a  different  posi- 
tion. It  falls  backward  when  man  is  upon  his  back,  and 
forward  as  the  dog  walks  about,  or  Hes  down. 

Historical  (1814-1903). — Wood  (1814)  wrote  an  interest- 
ing account  of  a  dissection  of  a  patient  in  which  a  foreign  body 
was  found  within  the  heart.  Sheward  and  Davis  also  report 
such  cases. 

Leaming  (1843)  mentions  a  case  of  a  needle  entering  the 
right  breast,  and  finally  lodging  in  the  heart,  causing  death. 
Graves  (1847)  relates  a  remarkable  case  of  suicide,  and  ex- 
traction of  a  needle  from  the  substance  of  the  heart.  Neill 
(1849)  ^Iso  relates  such  a  case,  resulting  in  death.  White 
(1853)  reports  a  case  of  aneurysm  of  the  left  axillary  artery, 
with  ligature  of  subclavian  artery,  and  lodgement  of  a  musket- 
ball  in  the  heart. 

In  the  case  of  Greene,  a  needle  that  had  lodged  in  the 
right  bronchus,  and  perforated  the  heart,  produced  death. 
Hamilton  (1867)  reports  a  gunshot  wound  of  the  heart,  the 
ball  being  embedded  in  the  wall  of  the  right  ventricle  for 
twenty  years.  Death  resulted  from  pneumonia.  Balch 
(1867)  also  had  a  case  in  which  the  ball  remained  in  the 
heart  for  twenty  years.  Ambrose  (1870)  recorded  a  case  of 
a  pin,  that  had  become  encysted  in  the  wall  of  the  heart. 


190  THE  SURGERY  OF  THE  HEART 

Callender  (1871)  successfully  removed  a  needle  that  had 
entered  the  heart,  and  the  patient  made  a  perfect  recovery. 
This  seems  to  be  the  first  surgical  operation  successfully  per- 
formed upon  the  heart. 

Ryerson  reported  a  needle  in  the  heart.  Halley  (1878) 
reports  a  case  of  a  ball,  fifty-five  days  in  the  heart,  causing 
death  while  the  man  was  working  in  the  field.  Fayrer  (1879) 
reports  an  interesting  case  of  a  dissection  of  a  case,  in  which 
a  foreign  body  was  found  within  the  heart.  Murdock  (1880) 
mentions  a  case  of  a  thorn  in  the  heart.  Balch  (1882)  had 
another  case  in  which  a  ball  remained  in  the  heart  for  eighteen 
years.  He  recovered  from  effects  of  wound  in  six  weeks. 
Ferris  (1882)  reports  a  case  of  a  man  living  twenty  days,  with 
a  skewer  traversing  his  heart. 

Pool's  (1889)  case  survived  eleven  days,  with  a  bullet  em- 
bedded in  the  apex  of  the  heart.  Polland  alludes  to  a  case 
in  which  a  lad  lived  five  weeks,  with  a  piece  of  wood  in  the 
right  ventricle.  Agnew  cites  another  case,  in  which  the 
patient  survived  three  weeks  with  a  watchmaker's  file  in  his 
heart,  the  tool  having  passed  through  the  left  ventricle  and 
right  auricle.  Haller  reported  (Agnew)  the  case  of  a  needle 
being  found  in  the  heart  of  a  bullock.  Iverhardt  reported 
twenty-two  cases  of  needle  in  the  heart  (nineteen  of  which 
were  discovered   post-mortem),   w'hich  were  not   suspected. 

BIBLIOGRAPHY 

Wood,  W.,  Edinb.  Med.  and  Sjirg.  Jour.,  1814,  X,  50-54. 
Sheward,  G.,  London  Med.  Gan.,  1834,  XIV,  541-543. 
Davis,  T.,  Tr.  Prov.  Med.  and  Surg.  Assn,  London,  1834,  II, 
357-360;  I  pi.     Also  London  Med.  Gas.,  1834,  XIV,  345. 
Leaming,  B.  F..  Med.  Exam.,  Philadelphia,  1843,  VI,  112. 
Graves,  J.  G.,  Analyst,  New  York,  1847,  II,  50. 
Neill,  J.,  Med.  Exam.,  Philadelphia,  1849,  "-S-i  V,  93-95. 
White,  W.,  Indian  Am.  Med.  5(^f..  Calcutta,  1853, 1,  289-295. 


Plate   XXIII. 


X  97. 

Carcinoma,  (Epithelial). 


*>*.; 


*r"   4', 


X  2G0. 

Carcinoma,   (Deep-Seated). 


(Chapter  on  Malignant  Tumors.) 


FOREIGN   BODIES  191 

Ingram^  S.  L.,  Remarkable  Phenomena  of  the  Heart,  Virginia 

Med.  Jour.,  Richmond,  1859,  XII,  378. 
Balch^  G.  B.,  Am.  Journal  Med.  Sc,  Philadelphia,  1861,  n,s., 

XLII,  2893.     Also  Med.  Repor.,  New  York,   1867-68, 

n.s.,  I,  91. 
Green,  T.  H.,  Tr.  Path.  Soc,  London,  1866,  XVII,  89. 
Hamilton,  New  York  Medical  Journal,  1867,  IV,  379-382. 
Ambrose,  D.  R.,  Med.  Rec.,  New  York,  1870,  V,  83. 
Callender,  Proc.  Roy.  Med.  and  Surg  Soc,  London,  1871, 

1875,  VH,  p.  116. 
Ryerson,  T.,  Tr.  Med.  Soc.  New  Jersey,  Newark,  1877,  259. 
Fayrer,  J.,  Lancet,  London,  1879,  I,  658. 
H ALLEY,  Of  Conn.,  1878. 

Murdoch,  E.  P.,  Peoria  Med.  Monthly,  1881,  I,  135. 
Balch,  Gross,  Surgery,  Vol.  II,  1882,  382. 
Davis,  Gross,  Surgery,  1882,  Vol.  II,  p.  382. 
Ferris,  Gross,  Surgery,  Vol.  II,  1882,  p.  382. 
Pool,  Agnew's  Surgery,  Vol.  I,  1889,  424. 
Sengenesse,  B.,  Considerations  sur  un  cas  de  corps  etranger 

du  coeur  chez  un  enfant  de  trois  ans.     A?in.  de  la  Policlin. 

de  Bordeaux,  1893-94,  III,  249-260. 
Haller,  Bibliotheca  Chirurgica,  Vol.  II,  p.  378. 
IvERHARDT,  Aguew's  Surgcry,  Vol.  I,  p.  425. 
Polland,  Reported  by  David  and  Stewart  Syst.  of  Surg.,  Vol. 

II,  p.  606. 


CHAPTER  X 
CARDIOLITHS 

Cardioliths  and  concretions  are  quite  common,  and  orig- 
inate from  the  blood,  polypoid  growths,  clots,  or  microorgan- 
isms. If  a  nucleus  be  present,  it  may  be  any  foreign  body  that 
may  have  entered  the  substance  of  the  heart,  or  any  of  its 
chambers.  Cardioliths  may  enter  any  chamber  after  having 
formed  in  any  portion  of  the  cardiac  substance,  and  at  once 
become  foreign  bodies,  and  might  be  so  classed. 

Historical  (1700-1903). — Goodwin  (1700)  recorded  a 
case  of  polyform  concretions  of  the  heart.  At  the  same  time 
he  reported  several  cases  of  stones  in  the  heart.  Vernon 
( 1826)  gives  quite  a  lengthy  report  of  a  case  of  obstruction  to 
the  passage  of  blood  through  the  right  auriclo-ventricular 
opening  of  the  heart,  from  a  fibrous  concretion,  which  was  en- 
tangled under  the  tendinous  cords  of  the  tricuspid  valve. 
Bricheteau  (1834)  reported  a  similar  concretion  of  a  fibrous 
character.  Hache  (1832)  found  such  concretions  in  a  tuber- 
culous subject.  Aubrey  (1836)  observed  fibrous  concretions, 
causing  obstruction  to  the  circulation.  He  thought  them  to 
be  due  to  microorganisms.  Hardy  (1838)  attributed  their 
formation,  in  his  case,  to  a  vegetable  ferment.  Hughes  (1838) 
reported  his  observations  on  fibrous  concretions,  in  eleven 
cases. 

Bouilland  (1839)  believed  that  the  concretions  found  in  his 
patient  were  from  the  blood  alone.  In  the  case  of  Sprague 
(1848)  there  were  fibrinous  concretions  in  the  heart,  extending 
into  the  pulmonary  artery  and  aorta  with  extensive  hepatiza- 

192 


CARDIOLITHS  I93 

tion  of  both  lungs.  Garstang  ( 1852)  mentions  a  case  of  death, 
clue  to  a  fibrinous  concretion  of  the  heart.  Barbieri  (1852) 
of  Milan  reports  a  case,  in  which  a  fibrous  polyp  extended  from 
the  ventricle  through  the  aortic  orifice. 

Richardson  (1855),  it  seems,  was  among  the  first  to  write 
upon  the  diagnosis  of  fibrous  concretions  in  the  heart.  Blondet 
(1857)  wrote  voluminously  upon  the  subject,  but  could  offer 
nothing  definite  in  determining  their  cause  or  presence.  Haus- 
ley  (1858)  reported  a  death  from  a  fibrous  concretion  in  the 
right  heart.  Its  presence  in  the  right,  is  less  frequent  than  in 
the  left  heart.  It  remained  for  Ogle  (1862)  to  report  the 
largest  cardiolith.  It  was  globular,  and  one  inch  in  diameter, 
"  lying  loose  "  within  the  left  auricle  of  the  heart.  It  was 
fibrous  in  character.  There  was  induration  of  the  suprarenal 
capsules. 

During  the  year  1864  Faure  made  an  experimental  research 
concerning  fibrinous  clots  and  the  products  of  inflammation.  In 
1866  he  reported  upon  a  case  of  extensive  fibrinous  concretions 
in  the  heart.  Monard  (1867)  wrote  an  interesting  paper  on 
the  general  considerations  of  concretions  found  in  the  blood. 
Faure  and  Monard  deserve  much  credit,  as  they  were  among 
the  first  to  explain  the  character  of  these  bodies. 

Barbancy  (1869)  appears  to  be  the  first  to  report  fibrous 
concretions  as  being  due  to  pneumonia.  Fayrer  (1870)  states 
that  death  was  due  to  fibrinous  concretions  in  the  right  side  of 
the  heart,  in  a  subject  suffering  from  urethral  fever.  It  is  pos- 
sible that  in  each  of  these  cases  the  presence  of  concretions  was 
coincidental.  Fayrer  (1873)  reports  another  case,  in  which  a 
fibrous  concretion  was  found  in  the  right  heart.  Lawson 
(1873)  reports  two  such  cases.  Baker  (1874)  found  them  in 
the  heart  and  large  vessels.  Hattute  (1875)  ^"^  Rendue 
(1875)  ^^ch  report  concretions  found  in  the  heart  of  tuber- 
culous subjects. 

Chaffey  (1887)  mentions  a  case,  in  which  fibrous  deposits 
were  found  in  the  heart  of  a  patient  having  diphtheria.     May- 


194  THE  SURGERY  OF  THE  HEART 

cock  ( 1888)  States  that  he  found  pecuhar  deposits  in  the  heart 
and  aorta,  while  Delepine  ( 1889)  describes  a  cardiohth. 


BIBLIOGRAPHY 

Goodwin,  J.  W.,  Phil.  Tr.,  London,  1700,  III,  70-76;  i  pi. 

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Vernon,  H.,  Edinburgh  Med.  and  Surg.  Jour.,  1826,  XXVI, 

76-79. 
Brichetau,  Jour.  Jlebd.  dc  Prog,,  de  Sc.  et  I'lnst.  Med.,  Paris, 

1834,  IV,  39-44. 
Aubrey,  Rec.  de  mem.  de  Med.  Mil.,  Paris,  1836,  XL,  270- 

281. 
Hardy,  Paris,  1838. 
Hughes,  H.  M.,  Guy's  Hospital  Rep.,  London,  1839,  IV,  146- 

190;  2  pi.     Also  Med.  and  Surg.  Monographs,  80,  Phila., 

1840,  105,  136. 
BouiLLAND,  Experience,  Paris,  1839,  III,  273,  337. 
JoY,  W.  B.,  Polypous  concretions  of  the  heart.     System  Pract., 

M.  Tweedie,  Philadelphia,  1841,  III,  556-560. 
Epidemic  de  concretions  fibrineuses  du  ccEur.     Rec.  de  Med. 

Mil.,  Paris,  1842,  III,  63-71. 
Sprague,  G.,  Illinois  and  Indiana  Med.  and  Surg.  Jour.,  Chi- 
cago, 1848,  II,  402-6. 
Choisy,    Observation    de    polype    fibreux    du    coeur.       Soc. 

Med.  de  Gannat,  Rap.  gen,  etc.,  Cusset,  1848-49,  44-51- 
Garstang,  W.,  Lancet,  London,   1852,  II,  191.     Also  Med. 

Times,  London,    1852,  n.s.,   V,  259.    Also  Prov.   Med. 

and  Surg.  Jour.,  London,  1852,  658. 
Barbieri,  Gas.  Med.  Ital.  Lonih.,  Milano,  1852-53,  s.  Ill,  397- 

402. 
Barth,  Un  caillot  adherent  dans  le  ventricule  gauche  du  coeur 

formant  une  masse  ferme  et  resistante.     Bull.  Soc.  Anat. 

de  Paris,  1853,  XXVIII,  86-88. 
Richardson,  B.  W.,  Med.  Circ,  London,  1855,  VI.  193. 


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Blondet,  Union  Med.,  Paris,  1857,  XI,  463,  471,  485,  497, 

504,  516,  529. 
HousLEY,  C,  Med.  Times  and  Gac,  London,  1858,  XVI,  425. 
Ogle,  J.  W.,  Tr.  Path.  Soc,  London,  1862,  XIV,  127. 
Faure,  Produits  d'inflammation  du  coeur.    Arch  Gen.  dc  Med., 

Paris,  1864,  I,  129-150. 
Ogle,  Tr.  Path.  Soc,  London,  1866,  XVII,  71. 
MoNARD,  MontpeHer,  1867. 
Todd,  J.  S.,  Fibrinous  Concretions  in  the  Heart.     Am.  Jour. 

Med.  Sc.,  Philadelphia,  1869,  n.s.,  LVII,  109. 
Barbancey,  Bidl.  Soc.  Anat.  de  Paris,  1869,  XLIV,  1 91-193. 
Fayrer,  J.,  Jordian  A.  M.  St.  Calcutta,  1870,  No.  XXVII,  30- 

35- 
D'EspiNE,  Infarctus  multiples  dus  a  des  caillots  emprisonnes 

dans  les  anfractuosites  caverneuses  du  ventricule  gauche. 

Bull.  So'c.  Anat.  de  Paris,  1871,  XLVI,  59-61. 
Rendu,  Bull.  Soc.  Anat.  de  Paris,  1872,  XLVII,  405. 
Lawson,  R.,  Med.  Times  and  Ga^.,  London,  1873,  I,  138. 
Fayerer,  J.,  Med.  Times  and  Gan.,  London,  1873,  i,  58-60. 
Baker,  B.,  Canada  Med.  Rec,  Montreal,  1874-75,  III,  429- 

434- 
Hattute,  Rec.  Mem.  de  Med.  Mil,  Paris,  1875,  XXXI,  250- 

262. 
Burnett,  W.   R.,  Heart  with  Calcareous  Plates.     Tr.   Path. 

Soc,  London,  1881,  XXXII,  53. 
Ribrail,  Polypes  Fibrineux  du  Coeur.     Bull.  Soc.  Anat.  de 

Paris,  1883,  LVIII,  191-193. 
Roy,  G.  C,  Fibrinous  coagula  in  the  heart.     Indian  Med.  Gaa., 

Calcutta,  1883,  XVIII,  117-119. 
Williams,   A.   D.,    Cardiac  Thrombosis.     Asylum   Med.   J., 

Berbice,  1884,  No.  362. 
Cenas,    Concretion   sanguine   remplissant  Toreillette  gauche. 

Loire  Med.,  St.  Etienne,  1886,  V.  169-177. 
Schmidt,  M.,  Ein  fall  von  Concretio  Cordis.      Deut.   Med. 

IVoch.,  1886,  XII,  936. 
Chaffey,  W.  C,  Brit.  Med.  Journal,  London,  1887,  II-  i-i- 


196  THE  SURGERY  OF  THE  HEART 

MoGLiA,  C,  Un  caso  di  thrombosi  purulenta  del  cuore  de  metas- 

tari.     Morgagni,  Napoli,  1887,  XXIX,  623-630. 
Maycock,  B.  J.,  Med.  Rcc,  New  York,  1888,  XXXIV,  703. 
Delepine,  S.,  Tr.  Path.  Soc,  London,  1889-90,  XLI,  43-53; 

I  pi. 
Edwards,  W.  A.,  Some  Unusual  Heart  Clots  with  Remarks 

upon  White  Thrombi.     Pacific  Med.  Jour.,  San  Fran- 
cisco, 1889,  XXXII,  657-660. 
Banks,  C.  E.,  The  Frequency  of  Heart  Clots.     Rep.  Superv. 

Surg.-Gen.    Marine    Hospital,    Washington,    1 890-1 891, 

XIX,  loi. 
Von  Ziemssen,  Zur  Pathologic  und  Diagnose  der  Gestelten 

und  Kugelthromben  des  Herzens.     Verhandhing  d.  cong. 

f.  inner  Med.,  Wiesbaden,  1890,  IX,  281-285. 
Gem  MEL,  J.  F.,  A  Case  of  Cardiac  Thrombosis  with  Multiple 

Embolism  of  the  Lungs;  necropsy.    Lancet,  1891,  I,  1041. 
Berge,  a..  Polype  Fibrineux  de  I'Oreillette  Gauche.     Bull., 

Soc.  Anat.,  Paris,  1892,  LXVII,  323-325. 
Stance,  P.,  Uber  einen  fall  von  Kugelthrombus  im  vorhof  des 

linken  Herzens.     Gottingen,  Berlin,  1893. 
Krumbholz,  Zur  Casuistik  des  gestelten  Herzpolypen  und  der 

Kugelthromben.     Arh.  a.  d.  Med.  Klin,  su  Leipsic,  1893, 

328-331. 
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f.  Klin.  Med.,  Leipsic,  1894-95,  LIV,  189-200. 
March  and,  F.,  Zur  der  Embolic  und  Thrombose  der  Gehirn- 

arterien  zu  gleich  ein  beitrag  zur  Casuistik  der  primar- 

ten  Herztumoren  under  der  gekreutzen  Embolic.    Berlin 

Klin.  Woch.,  1894,  XXXI,  i,  36,  62. 
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vita.     Settimana  Med.  de  Sperimentale,  Firenze,   1896, 

I,  87-89. 
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mitralis  aortse  et  triscuspidalis.      Tod.   Jahrh.   d.    IVien. 

k.  k.  Krankenanstalt,  1895,  Wien  and  Leipsic,  1897,  IV, 

pt.  2,  238. 


CARDIOLITHS  197 

Allais,  a.,  Contribution  a  I'Etude  de  la  Thrombose  Cardiaque, 

Paris,  1898. 
Varnali  and  Jonescu^  Uber  einen  fall  von  Concretio  Cordis 

mit  Herzdilatation.     Med.  Chir.   Ccntrhl.,  Wien,    1898, 

XXXIII,  572. 
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XX,  327-332. 
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1900. 


CHAPTER    XI 
CALCIFICATION 

Calcification  is  a  deposit  of  calcium  carbonate  or  phos- 
phate often  found  associated  with  some  of  the  salts  of  mag- 
nesium. It  may  be  deposited  in  the  endothelium  on  the  inter- 
muscular fibres.  It  is  usually  preceded  by  fibrosis  and  due  to 
weak  circulation,  and  chronic  irritation. 

Gibson  says  "  the  nature  of  the  process  which  leads  to  the 
deposition  of  lime  salts  is  absolutely  unknown,"  and  that  no 
more  definite  hypothesis  can  be  assumed  at  present  than  that 
soluble  become  altered  into  insoluble  salts. 

Historical  (1822-1903). — Rost  (1822),  Rainy  (1827), 
Richardson  (1830),  Pierson  (1834),  Douglas  (1838),  Wood 
(1850),  and  Pierce  (1852),  have  found  ossific  formations  in 
the  heart,  the  last  named  having  also  observed  them  in  a  hog. 
Wilks  (1856),  Cleveland  (i860).  Gay  (1872),  and  Egan 
(1876),  also  mention  cases.  In  the  case  of  Eskridge  (1884), 
the  ossification  was  at  the  aortic  orifice. 

Emmet  (1855)  reports  a  case  of  calcareous  deposits  on  the 
surface  of  the  heart,  with  reference  to  the  manner  in  which  the 
blood  is  propelled  from  that  organ.  Ogle  (1859)  had  a  case 
in  which  such  deposits  surrounded  the  heart  substance.  Coats 
(1871)  had  a  similar  case,  and  reported  two  cases  of  calcare- 
ous infiltration  of  the  muscular  fibres  of  the  heart.  Harduch 
(1880)  observed  a  similar  one,  and  O'Toole  (1880)  found  in- 
filtration in  the  apex  of  the  heart,  at  the  same  time  writing 
extensively  on  the  aetiology  and  pathology  of  such  infiltration. 

Rechardiere   (1883)   recognized  these  deposits  about  the 


CALCIFICATION  199 

aortic  valves  and  ventricular  walls.  Robin  (1885),  Guinou 
(1885),  Drummond  (1888),  Wolff  (1891),  Bromwell 
(1895),  and  Bromwell  and  Gulland  (1896),  and  Faitout 
(1896),  all  report  interesting  cases  of  this  character. 

BIBLIOGRAPHY 

RosT,  T.,  Med.  and  Phys.  Jour.,  London,  1822,  XLVIII,  474. 

Rainy,  A.,  London  Med.  and  Phys.  Jour.,  1827,  n.  s.,  Ill,  480-482. 

Richardson,  J.,  Glasgow  Med.  Jour.,  1830,  III,  397. 

PiERSON,  A.  L.,  Med.  Mag.,  Boston,  1834,  III,  29. 

Chalignez,  J.,  Extrait  d'une  memoire  des  cristaux  a  quatre  cris- 
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Douglas,  G.  M.,  Boston  Med.  and  Surg.  Jour.,  1838,  XVIII,  156. 

Wood,  J.,  Tr.  Path.  Soc,  London,  1850,  III,  66. 

Pierce,  J.  L.,  Am.  Med.  Jour.  Sc,  Philadelphia,  1852,  n.  s.,  XXIV, 
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Emmet,  T.  A.,  New  York  Med.  Times,  1855,  IV,  154-159. 

WiLKS,  Tr.  Path.  Soc.  London,  1856-57,  VIII,  100. 

Ogle,  J.,  Tr.  Path.  Soc.  London,  1859-60,  XI,  71-76. 

Cleveland,  W.  F.,  Lancet,  London,  i860, 1,  92. 

Coats,  J.,  Glasgow  Med.  Jour.,  1871-72,  IV,  433-451. 

Gay,  N.,  Tr.  O.  M.  Soc,  Cincinnati,  1872,  14;  also  Cincinnati 
Med.  News,  1872, 1,  328;  also  Med.  and  Surg.  Reporter,  Phila- 
delphia, 1872,  XXVII,  3. 

Egan,  R.  W.,  Brit.  Med.  Jour.,  London,  1876,  II,  749. 

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O'Toole,  M.  C,  Tr.  Med.  Soc,  California,  1880,  X,  118-121. 

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Richardiere,  Atherome  generalise,  retrecissement  aortique  avec 
atherome  des  valvules  aortiques,  calcification  de  I'endocarde 
du  ventricule  gauche.  Bull,  de  la  Soc.  Anat.,  Paris,  1883, 
LVIII,  499.  Calcified  pericardium;  double  mitral  disease. 
Bost.  Med.  and  Surg.  Jour.,  1884,  CX,  37. 


200  THE  SURGERY  OF  THE  HEART 

EsKRiDGE,  J.  T.,  Tr.  Path.  Soc,  Philadelphia,  1881-83,  1884,  XI, 
89.  Fibrous  and  calcareous  degeneration  with  stenosis  of 
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slit.     Tr.  Path.  Soc.  London,  1884-85,  XXXVI,  144. 

Robin,  A.,  Bull,  et  mem.  Soc.  Med.  d.  hop,  Paris,  1885,  II,  99-101. 

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GuiNOX,  L.,  Bull.  Soc.  Anal.,  Paris,  1885,  LX,  514. 

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Philadelphia,  1890,  XCIX,  153-158. 

Borchers,  C.  W.,  Uber  compHkation  von  amyloid-entartung  mit 
endokarditis.     Kiel,    1889. 

Rothschild,  A.,  Uber  die  entstehung  der  herzschwielen.  Freiburg, 
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XXIX,  219-265. 

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98,  VIII,  99-102.  Von  Reckhnghausen  uber  die  storungen 
des  myocardium.  Verhandlung,  Interna.  Cong.  Med.,  1890, 
BerHn,  1891,  II,  3  Abth.  67-74.  Von  Zenker  Storungen  des 
myocardium  Verhandlung  z.  x.,  Intemat.  Med.  Cong.,  1890. 
Berhn,  1891,  II,  3  Abth,  74-81. 

Wolff,  L.,  Tr.  Path.  Soc.  Philadelphia,  1891,  XVI,  136. 

OsLER,  W.,  Anaemic  necrosis  of  the  heart  muscle.  Tr.  Path.  Soc, 
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Kast  and  Rumpek,  Myodegeneratio  cordis  et  thrombosi  arteriae 


Plate  XXIV 


X  47. 

Cysticercus. 


X  75. 

Eggs  of  Cysticercus. 


(Chapter  on  Animal  Parasites.) 


CALCIFICATION  20I 

coronariae;  ancurysma  cordis  continens  in  eis.  Path.  Anat. 
Tafeln.  Hamb.  Staatskrankenhaus,  Wandsbek.  Hamb.  1893, 
7  hft.  pi.  C  4,  with  text. 

RoNDE,  J.,  Zur  aetiologie  der  herzschwielenbildung.  Wurzburg, 
1893. 

LipPERT,  H.,  Uber  amyloidentartung  nach  recurrirender  endo- 
carditis.    Tubingen,  1895. 

Bramwell,  B.,  Tr.  Med.  Chir.  Soc,  Edinburgh,  1895-96,  XV,  97, 

lOI. 

Dehio,  K.,  Die  diffuse  vermehrung  des  bindegewebs  im  herz- 

fleische    (myofibrose).     Verhandlung  d.   cong.  innere   Med., 

Wiesbaden,  1895,  XII,  487,  495. 
GuRViCH,    M.    I.,    Myofibrosis    cordis    patholoanatomischeskoye 

izsUcdovanie  (patho-anatomical  research).     Yuryew,  1896. 
Bramwell  and  Gulland,  Edinburgh  Hosp.  Report,  Edinburgh 

and  London,  1896,  IV.,  1575,  199;  2  pi. 
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Med.  Jour.,  St.  Petersburg,   1897;  CLXXXIX,  Med.-Spec. 

pts.  1122-1135. 
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tydning  Norsk.     Mag.  f.  Leagevidensk,  Kristiana,  1897;  4  R., 

XII,    1027,    1041. 
Lemoine,  La  myocardite  parenchymateuse.     Rev.  Prat.  d.  Trav. 

de  Med.,  Paris,  1897;  LIV,  161.    Myofibrosis  cordis.    Compt. 

Rend.  Cong.  Internat.  de  Med.,  1897;  Moscow,  1899,  III, 

Sect.  5,  271-275. 
Hervouet,   Sur  un  cas  de  cirrhose   cardiaque.     Gaz.  Med.  de 

Nantes,  1898,  1899,  XVII,  5052. 
Jacobsthal,  H.,  Verhaltung  von  herzmuskelfasen  bei  einem  kinde. 

Arch.  f.  Path.  Anat.,  etc.,  Berlin,  1900;  Clin.,  361-4. 
Gibson,  C.  A.,  Acute  heart  softening.     Edinburgh  Hospital,  1900, 

VI,  40-8. 
VON  Pessel,  F.,  Calcification  of  the  heart.    Munchen.Med.  Woch., 

June  10,  1902. 


CHAPTER    XII 
ABSCESS 

Abscess  of  the  heart  is  usually  py?emic,  and  associated  with 
disease  of  the  bones  and  joints,  cancer,  phlebitis,  myocarditis, 
and  chronic  ulcers,  especially  about  the  genito-urinary  tract. 

Cardiac  abscesses  occur  as  multiple  yellow  spots  under  the 
pericardium  or  endocardium,  varying  in  size  from  a  millet-seed 
to  a  bantam's  egg,  and  situated,  as  a  rule,  at  the  base  of  the  left 
ventricle  in  the  papillary  muscles.  They  may  remain  semi- 
solid, or  they  may  contain  fluid  and  rupture  into  the  peri- 
cardial space,  or  into  one  or  all  of  the  chambers  of  the  heart, 
and  so  finally  enter  the  general  circulation.  Death  may  not 
ensue  from  either  kind  of  rupture,  the  result  depending  upon  the 
character  of  the  fluid,  its  amount  and  the  condition  of  the  pa- 
tient at  time  of  rupture. 

Historical  (1833-1903). — One  of  the  earlier  reports  of  ab- 
scess of  the  human  heart  is  by  Broussais  ( 1832).  Such  a  con- 
dition was  found  in  the  heart  of  a  horse  by  Parry  ( 1835). 

Hewitt  (1846),  mentions  a  remarkable  case  of  abscess  of 
the  heart,  with  pain  in  the  leg  as  the  only  symptom  during  life. 
Chance  (1846)  gives  an  account  of  abscess  of  the  heart  found 
post  mortem,  as  does  Stallard.  Mayne  (1847)  speaks  of  a 
purulent  cyst  of  the  heart;  McCormick  (1851)  of  an  abscess 
of  the  right  ventricle;  Rankin  (1852)  of  an  anomalous  case  of 
scrofulous  abscess;  Banks  (1852)  of  purulent  cardiac  cysts. 

Holmes  (1857)  mentions  a  secondary  cardiac  abscess  from 
pyaemia  in  the  heart-wall,  and  Maxon  ( 1869)  reports  a  case  of 
abscess  of  the  heart  bursting  into  the  left  ventricle. 


ABSCESS  203 

Wooster  (1872)  reports  a  case  of  abscess  of  the  heart-wall 
with  disease  of  the  valves,  incompetence  of  left  sigmoid  valves, 
physiological  tricuspid  incompetence,  and  anasarca,  with  pain- 
less death  by  gradual  asphyxia  from  super-carbonized  blood. 

In  1872,  Langluirst  mentions  a  scrofulous  abscess  in  the 
wall  of  the  left  ventricle,  as  does  Crisp  during  the  same  year. 
The  case  of  Crisp  was  due  to  pyaemia.  Maxon  ( 1872)  reports 
a  case  of  abscess  of  the  heart  and  kidneys  with  suppurative 
periostitis,  and  Dennis  (1895)  records  a  case  of  abscess  in  the 
wall  of  the  left  auriculo-ventricular  valves,  about  the  size  of  a 
walnut,  which  had  opened  into  the  ventricle.  The  duration 
could  not  be  determined  from  the  symptoms. 

Following  is  a  case  reported  to  me  direct. 

"  Dear  Doctor  :  With  regard  to  my  own  case  of  cardiac 
abscess,  I  briefly  reported  it  in  a  Chicago  medical  journal  I 
think  for  1877.  As  I  have  not  access  to  its  files  I  cannot  give 
you  the  references.  My  recollection  of  the  case  is  to  this  effect. 
A  hospital  patient  was  suffering  from  dyspnoea,  and  proved  to 
have  a  very  much  dilated  pericardium,  which  at  the  time  was 
considered  to  be  full  of  serum.  One  night  in  his  extremity  of 
distress,  I  decided  to  try  to  relieve  him  by  use  of  the  aspirator. 
You  will  recall  that  this  was  in  the  early  day  of  the  aspirator 
and  this  was  almost  my  first  experience  with  it.  I  pushed  a 
needle  in  and  withdrew,  not  serum,  but  to  my  surprise,  three 
or  four  ounces  of  pus.  The  man  was  temporarily  relieved  but 
died  a  few  hours  later.  Autopsy  showed  a  pericardium  with 
considerable  serum  and  an  abscess  cavity  of  the  heart-wall 
nearly  emptied,  into  which  my  needle  point  must  have  pene- 
trated. 

"  Whatever  else  may  be  said  about  the  case,  I  think  I  may 
certainly  claim  accidental  priority  in  tapping  an  abscess  in  this 
locality.  "  Very  truly  yours, 

"RoswELL  Park. 

"Buffalo,  N.  Y.,  October  4,  1902." 


204  THE  SURGERY  OF  THE  HEART 


BIBLIOGRAPHY 

Broussais,  C,  Ann.  de  la  Med.  Physiol.,  Paris,  1832. 

Krauss,  Eiterabscess  in  der  herzsubstanz.  Med.  Correspond- 
ence Blatt.,  d.  Wiirtemburg.  Aerztl.  von  Stuttgart,  1833,  II, 
189-191. 

Parry,  R.  B.,  Indian  Med.  Jour.  Sc,  Calcutta,  1835,  II,  299. 

GoiTRAC,  Cordite  partielle,  abces  du  sommet  du  ventricule  gauche, 
trajet  fistuleux  ouvrant  a  la  surface  du  cceur.  Bull.  Acad. 
de  Med.,  Paris,  1842,  VIII,  856-859. 

Hewitt,  T.,  Lancet,  London,  1846,  I,  684. 

Chance,  E.  J.,  Lancet,  London,  1846,  I,  548-550. 

Stallard,  J.  H.,  Prov.  Med.  and  Surg.  Ass'n.,  London,  1847,  XV, 
105-116  ;  I.  pi. 

Mayne,  R.  St.  J.,  Proc.  Path.  Soc,  Dublin,  1847-52,  274. 

Beauvais,  Pericarde  adherent,  abces  du  coeur.  Ibid,  1847,  XXII, 
172. 

Lange,  E.  W.,  Abcess  des  herzens  in  his  bcob.  am  Krankenbette 
et  Konigsburg,   1850,   189-19 1. 

McCoRMiCK,  New  Orleans  Med.  atid  Surg.  Jour.,  1851-52,  VIII, 
890. 

Ranking,  R.,  Prov.  Med.  and  Surg.  Jour.,  London,  1852,  659. 

Banks,  J.  T.,  Proc.  Path.  Soc,  Dublin,  1852-58,  27. 

Barth,  Diathese  purulente;  un  nombre  de  foyers  purulents  dans 
les  muscles;  un  petit  abces  dans  les  parois  du  coeur.  Bull. 
Soc.  Anat.,  Paris,  1855,  XXX,  6. 

Holmes,  T.,  Tr.  Path  Soc,  London,  1857-58,  IX,  164. 

KiEMANN,  Periostitis  femoris,  oedema  et  hypertrophia  cerebri ;  peri- 
carditis, abscessus  cordi,  pneumonia  lobularis.  Der.  d.  k.  k. 
Krankenanstalt,  Rudolph  Siftung,  Wien  (1866),  1867,  223. 

Roth,  M.,  Ein  fall  von  herzabscess.  Arch.  Path.  Anat.,  etc.,  Ber- 
lin,  1867,  XXXVIII,   572-574. 

Maxon,  Tr.  Path.  Soc,  London,  1869,  XX,  113, 

Smith,  P.  H.,  Suppuration  of  the  heart.  Tr.  Path.  Soc,  London, 
1870,  XXI,  94. 


ABSCESS  205 

WoosTER,  D.,  Pacific  Med.  and  Surg.  Jour.,  1872,  VI,  324-8. 
LONGHURST,  A.  E.  T.,  Army  Medical  Dept.,  London,  1872,  XII, 

514.     Abscess  of  the  heart  and  kidneys  with  suppurative  peri- 
tonitis, a  distinct  kind  of  pyaemia.     Med.  Times  and  Gaz., 

London,    1872,   II,   351, 
Crisp,  E.,  Tr.  Path.  Soc,  London,  1872,  XXIII,  8794. 
Maxon,  Med.  Times  and  Gaz.,  London,  1872,  II,  351. 
Crisp,  E.,  Tr.  Path.  Soc,  London,  1872,  XXIII,  8493. 
Montard-Martin,   Abces   metastatique    du    cceur.     Bull.   Soc, 

Anal.,  Paris,  1875,  I,  775. 
BuRCKHARDT,   G.,   Fall  con  idiopatischen  herzabscess.     Corres- 

pondenz  Blatt.  Schw.  yErlze,  Basil,  1876,  VI,  475-480. 
Stevenel,  C,  Contribution  a  I'etude  de  la  myocardite  interstitielle 

et  de  I'abces  du  coeur.     Paris,  1882. 
RiCHET,   Aneurysme   du    coeur   et    abces   thoracique.      Semaine 

Med.,  Paris,  1884,  2  s.,  IX,  IV,  517. 
Allard,  J.,  Des  kystes  puriformes  du  cceur.     Paris,  1890. 
FoRMAD,  H.  F.,  Abcess  of  the  heart.     Tr.  Path.  Soc,  Philadelphia, 

1891-93,  XVI. 
Dennis,  Sys.  Surg.,  1895,  Vol.  I,  p.  405. 
Crouzon  AND  May,  Abces  metastatique  du  coeur.     Bull.  Soc. 

Anat.,  Paris,  1896,  LXXI,  860. 
Favir,  M.,  Abscessus  cordis.       Feldschr,  St.  Petersburg,  1899,  IX, 

349-351 


CHAPTER    XIII 
SYPHILIS 

It  has  been  conclusively  demonstrated  that  syphilis  causes 
a  large  proportion  of  the  more  serious  cardiac  affections,  espe- 
cially after  middle  life,  an  age  when  chronic  valvular  disease  is 
not  due  to  endocarditis.  Syphilis  is  often  associated  with 
other  factors  in  the  production  of  heart  troubles,  especially 
strain  and  alcoholism.  (Bruce,  British  Medical  Journal, 
]\Iarch  23,  1901.) 

Description  (1862-1903). — Syphilis  is  an  exciting  and  pre- 
disposing cause  of  muscular  and  valvular  lesions  of  the  heart. 

Cohn  believes  that  the  condition  of  the  heart  muscle  is  the 
most  important  point  to  consider  therapeutically,  and  for  the 
purpose  of  prognosis,  in  all  cardiac  diseases,  except  mitral  ste- 
nosis (Philadelphia  Medical  Journal,  Vol.  7,  No.  3,  p.  106, 
1 901)  ;  "  many  of  the  changes  in  the  heart-muscle  are  depend- 
ent upon  pathologic  changes  in  the  arterial  system." 

Many  cases  of  myocarditis,  especially  acute  cases,  are  due 
to  syphilis.  The  pain  in  cardiac  diseases  is  due  to  the  fact 
that  the  various  visceral  nerves  are  connected  with  the  nerves 
of  the  corresponding  parts  of  the  body.  The  greater  fre- 
quency of  myocarditis  in  negroes  is  on  account  of  syphilitic  in- 
fection. (Bishop,  Philadelphia  Medical  Journal,  Vol.  7,  No. 
3,  1901,  p.  106.) 

These  conditions  do  not  generally  begin  until  ten  to  twenty 
years  after  the  initial  lesion,  and  are  more  common  in  men  than 
in  women ;  they  are  slow  as  a  rule  in  manifesting  themselves 
and  the  prognosis  is  grave. 

206 


SYPHILITIC    GUMMATA  207 

Fibrosis  and  gummatous  deposits  constitute  the  two  forms 
of  syphilitic  affection  of  the  heart.  It  is,  however,  only  the 
gummatous  form  that  will  be  considered. 

Ricord,  Virchow,  and  Lancereaux  w^ere  among  the  first  to 
observe  gummata  in  the  heart.  They  showed  that  these  le- 
sions may  be  diffuse  or  circumscribed,  dry  and  yellow,  or  of  a 
caseous  character.  Such  infiltrations  may  occur  in  any  por- 
tion of  the  cardiac  tissue  and  undergo  fibrous  transformation. 
These  masses  do  not  soften  and  discharge  except  in  the  super- 
ficial heart  muscles. 

Haldane  in  1868  reports  a  case  in  which  he  found  a  syphi- 
litic deposit  in  the  substance  of  the  heart.  Pick  during  the 
same  year  recorded  one  of  fibroid  degeneration  of  the  heart 
with  aneurysm  in  the  right  ventricle  and  the  interventricular 
sseptum  in  a  syphilitic  patient.  There  are  several  cases  of  syphi- 
litic heart  affections  reported  during  the  ten  years  following 
that  of  Haldene.  Pepper  mentions  a  case  of  extensive  syphi- 
litic disease  of  the  pericardium,  pleura,  and  peritonaeum,  in 
which  a  paracentesis  of  the  chest  and  abdomen  w^as  made. 
Gummatous  infiltration  of  the  muscular  wall  of  the  heart  lead- 
ing to  aneurysmal  pouching  and  rupture  has  been  recorded  by 
Pitt,  and  also  by  Pelletier. 

BIBLIOGRAPHY 

Haldane,  D.  R.,  Edinburgh  Med.  Jour.,  1862,  VIII,  435-445. 
Pick,  T.  P.,  Tr.  Path.  Soc,  London,  XIX,  1869,  156-158. 
Fowler,  R,,  Fibroid   (probably  syphilitic)   degeneration  of  the 

heart.     Tr.  Path.  Soc,  London,  1868,  XIX,  1 08-1 11. 
Morgan,  J.,  Cases  of  syphiHtic  deposit  in  the  heart.     Med.  Press 

and  Cir.,  London,  1868,  VI,  425;  i  pi. 
Lego,  J.  W.,  Case  of  syphilitic  gumma  of  the  heart.     St.  Barth. 

Hospt.  Report,  London,  1872,  VIII,  183-185. 
Janeway,  E.  G.,  Syphilis  as  a  cause  of  heart  disease.     Med.  Fee, 

New  York,  1872,  VII,  304. 


2o8  THE  SURGERY  OF  THE  HEART 

McNalty,  G.  W.,  Syphilitic  gummata  of  the  heart.     Med.  Times 

and  Gaz.,  London,  1873,  !>  ^24. 
Smith,  R.  S.,  Syphiloma  of  the  heart.     Tr.  Brit.  Med.  and  Surg. 

Soc,  1874-78. 
Caylet,  Syphihtic  disease  of  the  heart.     Tr.  Path.  Soc,  London, 

1875,  XXVI,  32. 

Pepper,  W.,  Phil.  Med.  Times,  1876,  VII,  137. 

Gould,  A.  P.,  Case  of  syphihtic  heart.     Tr.  Path.  Soc.,  London, 

1876,  XXVII,  69. 

Shattock,  L.  G.,  Mucous  tumor  of  the  heart  (syphilitic  gumma) 

cordis,  specimen.     Tr.  Path.  Soc.,  London,  1881,  XXXII,  77. 
Henderson,  C.  G.,  Syphilitic  gumma  of  the  heart.     Tr.  Path. 

Soc,  London,  1882-83,  XXXIV,  53-55. 
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IX,  419. 
Profeta,  La,  Sifilide  acquisite  del  cuore  e  dello  sere  membrane 

serose.     Fugressia,  Palermo,  1885,  O,  160-165. 
Paste AUR,  W.,  A  Case  of  diffuse  syphiloma  of  the  heart.     Tr. 

Path.  Soc.  London,  1887,  XXXVIII,  105-107. 
Green,   A.   W.,   Ruptured    aneurysm    of    the    heart   (Syphihs). 

Tr.  Path.  Soc,  London,  1887,  XXXVIII,  102. 
Mathieu,  a.,  Syphihs.     Gaz.  d.Hop.,  Paris,  1888,  LVI,  163-165. 
Bargum,    O.,   Ein  fall   von   syphilis   der  myocardium.     Altona, 

1888. 
VoN  Der  Melbe,  A.,  Die  muskel-gummata  und  ein  neucs  gumma 

des  myocardium.     Wurzburg,  1888. 
Mayer,  G.,  Formas  curavers  des  molestias  chronicas  der  thoracac 

indusive  a  syphihs  cardiaca.     Rio  de  Janeiro,  1888. 
Aqua,  Sifhlopatia  cardiaca.     Rev.  Esp.  de  Ojtal.  Dermatol,  sij., 

etc.  Madrid,  1889,  XIII,  3-17. 
Maunac,  M.  N.,  Syphilis  of  the  heart,  including  the  valves.     Med. 

Obozr.,  Mosk.,  1889,  XXXI,  765-768. 
Long,  T.,  Die  syphilis  des  herzens.     Wien,  1889. 
Star  VINE,  A.,  Cuore  sifilitico  miocardite  cronica  interstiziale  gom- 

mosa  in  requito  e  infezione  sifilitica.     Prog.  Med.,  Napoli, 

1889,  III,   551-761. 


SYPHILITIC   GUMMATA  209 

Smyth,  J.,  Syphiloma  of  the  heart.  Tr.  South  Indian  Branch  Brit. 

Med.  Ass'n,  Madras,  1889,  III,  81. 
Sacharjin,  G.  a..  Die  lues  des  herzens  von  der  klinischen  seite 

betrachted.     Deut.  Arch.  Klin.  Med.,  Leipsic,  1889-90,  XL VI, 

388-397- 
Pelletier,  L.,  Arch,  de  Med.  et  Pharm.  Mil.,  Paris,  1890,  XV, 

369-372. 

Pitt,  G.  N.,  Tr.  Path.  Soc,  London,  1890-91,  XLII,  61. 

Palma,  p.,  Ein  Fall  von  luetischer  erkrankung  der  hnken  coro- 
narterie  des  herzens.     Prag.  Med.  Woch.,  1892,  XVII,  55-57. 

RoLLESTON,  H.  D.,  Multiple  syphilomata  in  wall  of  the  right  ven- 
tricle of  the  heart.     Tr.  Path.  Soc,  London,  1892-93,  XLIV, 

35- 
Semmola,  M.,  Lectures  on  cardiac  syphihs.     Med.  Press  and  Circ, 

London,  1893,  LV,  271-273. 

CusHMANN,  H.,  Herz  syphilis.     Arb.  a.  d.  Med.  Klin,  zu  Leipsic, 

1893,  226-236. 

De  Renzi,  E.,  SuUa  sifiHde  del  core.     Gazz.  d.  osp.,  Milano,  1893, 

XIV,  682-685. 
Kockel,  R.,  Beitrag  zur  pathologischen  anatomic  der  herzsyp- 

phiHs.     Arb.  a.  d.  Med.  Klin.,  Leipsic,  1893,  294-302. 
Mraeck,  F.,  Die  syphilis  des  herzens  bei  erworbener  und  ererbter 

lues  erzentrisch.     Arch.  }.  dermatol,  u.  syph.,  Leipsic,  1893, 

279-411;  4  pi. 
VoLMAR,  H.,  Ueber  gummata  des  herzens.     Kiel,  1893. 
Dehio,  K.,  De  syphilis  des  herzens.     St.  Petersburg  Woch.,  1894, 

XI,  407-410. 
Yamasaki,  K.,  Syphilitic  lesions  of  the  heart.     Tjishimpo,  Tokyo, 

1894,  No.  16,  56-62. 

Councilman,  W.  T.,  A  case  of  upward  syphihs  of  the  heart,    Med. 

and  Surg.  Reports,  Boston  City  Hospital,  1894,  5  s.,  85-92. 
Vetchtomoff,  E.,  Stuch  myocarditis  syphiliticae  Dnervnik  obsh. 

vrach.  pri  imp  Kazan  Univ,  1894,  II,  69-76. 
Hektoen,  L.,  a  case  of  multiple  foci  of  interstitial  myocarditis  in 

hereditary  syphilis.     Tr.  Path,   and  Bact.,   Edinburgh   and 

London,  1894-96,  III,  472-476. 


210  THE  SURGERY  OF  THE  HEART 

Fraenkel,  a.,  Demonstration  eines  preparates  von  herzsyphilis. 

Verhandlg.  Deut.  Berlin.  Med.  Gesellschajt,  1895,  XXV,  55-57. 
Israel,  O.,  Ein  fall  von  syphilitischer  endocarditis.     Berlin  Klin. 

Woch.,  1895,  XXXII,'  792. 
Jacquenet,  R.,  La  syphilis  du  coeur.     Gaz.  des  Hop.,  Paris,  1895, 

LXVIII,  917-925. 
LooMis,  H.  P.,  Syphilitic  lesions  of  the  heart.     Am.  Journal  Med. 

Sc,  Philadelphia,  1895,  337-340. 
O'DoNOVAN,  C,  A  case  of  syphihtic  endocarditis  causing  mitral 

valve  insufficiency.     Maryland  Med.  Jour.,  1895-96,  XXXIII, 

179-182. 
Mracek,  F.,  Klinisches  zur  herzsyphilis.     Med.  Chir.   Centrhl., 

1895,  XXX,  337-340. 

Rendu,  Note  sur  un  cas  de  syphilis  du  cceur  accompagne  de  pouls 
lent  permanent.  Bull,  et  Mem.  Soc.  Med.  d.  hop.,  Paris,  1895, 
3  s.,  XI,  381-386.  Sifihde  del  cuore.  Gazz.  d.  osp.,  Milano, 
1895,  XVI,  1137-1145. 

VoRMKOFF,  v.,  Doa  sluch  lues  cordis.  Vratch.  Zapiski,  Mosk., 
1895,  II. 

Wetchtomoff,  E.,  On  syphilis  of  the  heart,  case  of  myocarditis 
syphilitica  and  reply  of  Dr.  Kazenskon,  Moskva,  1895. 

De  Massary,  E.,  Un  cas  de  syphilis  cardiaque.  Bull.  Soc.  Anat., 
Paris,   1895,  LXX,   594-597- 

Baccarani,  U.,  Le  syphilide  de  cuore.  Rasegne  di  Soc.  Med., 
moderne,  1895,  X,  223,  227. 

Matani,  F.,  L'aritma  sifilitica.  Progresso  Med.,  Napoli,  1895, 
IX,  230-235. 

Smith,  R.  S.,  A  case  of  cardiac  disease  with  liver  enlargement, 
illustrating  the  probable  effects  of  syphilis  on  the  heart.  Clin. 
Jour.,  London,  1895-96,  VII,  145-149. 

Generisch,  a.,  a  very  singular  case  of  tuberculosis  and  gumma- 
tous disease  of  the  muscles  of  the  heart.  Orovosi  Hetil.  Buda- 
pest, 1896,  XL,  632-635. 

Duckworth,  D.,  A  case  of  sudden  death  due  to  cardiac  syphiloma. 
Tr.  Plin.  Soc,  London,  1896,  XXIX,  7-10. 

Lazereff,  N.  S.,  Combined  diseases  of  the  valves  of  the  heart  of 


Plate  XXV. 


X  500. 


Cysticercus,  (Bladder  Stage). 


(Chapter  on  Animal  Parasites.) 


SYPHILITIC    GUMMATA  211 

syphilitic  origin.    Voyenno  Med.  Journal,  St.  Petersburg,  1896, 

CLXXXVI,  I  sect.,  415-433. 
CoGGERSHALL,  F.,  A  case  of  syphilis  of  the  heart.     Boston  Med. 

and  Surg.  Journal,  1896,  CXXXV,  593-599. 
Gerhardt,  C,  Pericarditis  syphihtica.     Charite  Ann.,  1896,  XXI, 

153-156. 
Lazarew,  N.  S.,  Deux  cas  de  syphihs  du  cceur.     Presse  Med., 

Paris,  1896,  676. 
Phillips,  S.,  Syphilitic  diseases  of  the  heart  wall.    Lancet,  London, 

1897, 1,  223-231,  Cardiac  syphihs  in  the  production  of  cardiac 

disease  has  received  less  attention  than  it  deserves.     "  Year 

book,"  Gould,  1897,  p.  147.     Cardiac  syph.  etc.  (as  above). 
Bryant,  Sudden  death;  syphihtic  fibroid   disease  of  the  heart. 

Guy's  Hospital  Gaz.,  London,  1897,  XI,  53. 
Herrick,  J.  B.,  Syphilis  of  the  heart.     Fort  Wayne  Med.  Jour., 

Mag.,  1897,  XVII,  61-65. 
Grossman,  Uber   die   acquirirte   syphilis   des  herzens.     Milnch. 

Med.  Woch.,  1897,  XLIV,  473,  506,  522. 
Gespil,  Herz  syphilis.     Jahrb.  d.  gesellsch.  /.  Med.  und  Heilk.  in 

Dresden,  1897-98,  43. 
Lecount,  E.  R.,  Gummata  of  the  heart  in  a  case  of  congenital 

syphihs.     Journal  Am.  Med.  Ass'n.,  1898,  XXX,  181. 
Jaccoud,  Cardiopathie  syphilitique.     Rev.  Prat,  de  Trav.  de  Med., 

Paris,  1898,  LV,  249-251. 
Preis,  N.,  Syphilis  of  the  heart.     Meditisma,  St.  Petersburg,  1898, 

X,  41,  4,  19. 
Adler,  I,  Observations  on  cardiac  syphilis.     N.  Y.  Med.  Journal, 

1898,  LXVIII,  577-584. 
Babes,  Die  syphilis  des  herzens.  Heilkunde,Wien,  1898-99,  III,  191. 
CoMBENALE,  Role  dc  I'heredo-syphilis  dans  I'etiologie  de  certaines 

cardiopathies  valvulaires.     Echo  Med.  de  Nord,  Lille,  1900, 

IV,  419-421. 
Leared,  Aortic  valve  disease  apparently  caused  by  syphilis. 
Jacquinet  refers  to  rarity  of  cardiac  syphilis  up  to  this  time,  only 

102  cases  reported  and  of  these  only  sixty-one  trustworthy 

and  complete.     Gaz.  des  Hop.,  No.  3,  p.  917. 


CHAPTER    XIV 
GANGRENE 

Gangrene  of  the  heart  is  the  least  frequent  of  the  dis- 
eases herein  mentioned. 

Historical  (1850-1903). — The  first  case  reported  is  by 
Gaullay,  1807;  it  is  hardly  more  than  a  casual  mention.  Ken- 
nedy (1824),  however,  is  more  explicit  in  his  report  of  a  case 
of  acute  carditis  terminating  in  gangrene  of  the  heart,  with 
illustrations  of  the  same  lesion  determined  by  other  forms  of 
disease. 

Cruveilhier  (1850)  made  some  interesting  observations 
upon  its  pathology  and  maintained  that  it  could  occur  as  an 
independent  disease.  Young  (1868)  reported  a  case  of  gan- 
grene of  the  heart  and  Oulmout  mentioned  an  eruption  simu- 
lating rubeola,  cyanosis,  and  oedema  in  a  case  of  gangrene  of 
the  heart.     Gesland  also  reports  a  case  of  cardiac  gangrene. 

BIBLIOGRAPHY 

Gaullay,  Jour,  de  Med.  Chir.  Pharm.,  Paris,  1807,  XIII,  7-19. 
Kennedy,  London  Med.  Reporter,  1824,  4  s.,  I,  269,  284. 
Cruveilhier,  Bull.  Soc.  Anat.,  Paris,  1850,  XXV,  167. 
Young,  D.  S.,  Cincinnati  Med.  Repository,  1868, 1,  137,  143. 
Oulmout. 


212 


CHAPTER    XV 

BENIGN    TUMORS— FIBROMATA,    LIPOMATA,    ANGEIO- 
MATA,    RHABDOMYOMATA,    MYXOMATA,    POLYPI 

FIBROMATA. — Of  tumors  of  the  heart,  the  most  common 
are  the  fibromata,  but  while  fibroid  degeneration  of  the  heart 
is  frequent  and  may  involve  a  part,  or  all  of  the  muscular 
structures,  it  rarely,  if  ever,  takes  the  form  of  a  tumor.  The 
latter  may  develop  in  any  of  the  heart's  structures,  principally 
in  the  muscles. 

Historical  (1852-1903). — Gull  (1852)  found  a  fibroid 
tumor  attached  to  the  muscular  tissue  of  the  left  ventricle  of 
the  heart  of  a  sheep.  Elliott  (1856)  found  one  in  the  right 
ventricular  wall  of  a  human  heart.  In  this  case  there  were  a 
sacculated  aneurysm  and  dilatation  of  the  heart  as  a  result  of 
pressure.  Wilks  (1856)  discovered  a  fibrous  growth  in  the 
sseptum  ventriculorum  of  the  heart.  Hitchcock  (1856)  re- 
ports three  such  tumors  in  the  right  ventricular  wall,  associ- 
ated with  hypertrophy  of  that  wall. 

Wagstaff  (1871)  records  cases  of  cardiac  fibroid  and  Laid- 
ley  ( 1879)  gave  a  report  of  a  tumor  in  the  cardiac  wall.  Meigs 
( 1881 )  recorded  a  case  in  which  a  heart  clot  occurred  as  a  con- 
sequence of  ur?emic  convulsions  and  tumors  in  the  heart. 

Gairdner  (1893)  reports  a  very  interesting  case  of  obstruc- 
tion of  the  right  auriculoventricular  orifice  caused  by  a  tumor 
in  the  auricle  acting  as  a  ball  valve,  during  the  direct  current 
from  the  auricle  to  the  ventricle  and  without  other  apparent 
disease  of  the  valve  or  the  heart.  He  gives  clinical  comment 
on  diagnosis  and  prognosis. 

213 


214  THE  SURGERY  OF  THE  HEART 

Latnella  (1896)  records  a  pedunculated  fibroid  in  the 
heart,  and  Cesaris-Demie  (.during  the  same  year)  reported 
multiple  fibroids  of  the  heart,  while  Jachia  also  made  an  exten- 
sive contribution  to  the  study  of  fibroid  tumors  of  the  heart. 

Crawford  (1897)  records  a  case  of  fibroid  tumor  of  the 
pulmonary  valves  and  Raw  (1898),  one  in  the  right  auricle  of 
the  heart  with  rupture  of  the  inferior  vena  cava.  Knox 
(1899)  records  a  case  of  supra-arterial  epicardial  fibroid 
nodules. 


BIBLIOGRAPHY 

Gull,  W.,  Guy's  Hosp.  Report,  London,  1852,  SS,  VIII,  14^; 
I  pi. 

Elliott,  New  York  Medical  Times,  1856,  V,  236-8. 

WiLKS,  Tr.  Path.  Soc.,  London,  1856-57,  VIII,  150-155. 

Hitchcock,  H.  O.,  Boston  Med.  and  Surg.  Journal,  1856, 
LIV,  250-253. 

Wagstaff,  W.  W.,  Tr.  Path.  Soc.,  London,  1871,  XXII,  121- 
124. 

Yeo,  J.  B.,  Case  of  cardiac  tumor  of  the  cavity  of  the  left  ven- 
tricle.    Tr.  Path.  Soc.,  London,  1875,  XXVI.  52-55  ;  2  pi. 

McCracken,  J.  W.,  Tumors  in  the  cavities  of  the  heart.  Ohio 
Med.  Rec,  Columbus,  1876.  I,  114-116. 

Bramwell,  B.,  Tumor  of  the  exterior  of  the  heart.  Brit.  Med. 
Journal,  London,  1877,  I,  815. 

Laidley,  St.  Louis  Med.  and  Surg.  Journal,  1879,  XXXVI, 
264-266. 

Meigs,  A.  V.,  Tr.  College  Phys.,  Philadelphia,  1881,  3  s.,  V, 
19-27. 

Roberts,  J.  B.,  Tumor  of  the  heart.  Tr.  Coll.  Phys.,  Phila- 
delphia, 1 88 1,  3  s.,  V,  27. 

Ferguson,  Aneurysmal  dilatation  of  the  heart  and  mitral  ste- 
nosis; fibroid  induration.  Med.  Rec,  New  York,  1883, 
XXIV,  75. 


BENIGN   TUMORS  21  5 

Turner,  F.  C,  Multiple  growth  in  the  myocardium.     Illus. 

Med.  Nczvs,  London,  1888-89,  I>  45  5  i  pl- 
Loom  IS,  H.  P.,  Peculiar  tumors  in  the  heart  muscle.     Med. 

Rec,  New  York,  1889,  XXV,  106. 
Gairdner,  Edinburgh  Hospital  Rep.,  1893,  I,  221-234;  2  pi. 
Crawford,  Tr.  Path.  Soc,  London,  1897-98,  XLIX,  37-41. 
Raw,  British  Medical  Journal,  London,  1898,  II,  1335. 
Knox,  Jour.  Exp.  Med.,  New  York,  1899,  IV,  245-260;  3  pi. 
Traina,  R.  I.,  Tumor  primitivi  del  cuore.     Clinical  Medccine 

Ital,  Milan,  1902,  XLI,  65-81 ;  i  fig. 


LIPOMATA  (1886-1903). — Lipomata  of  the  heart  are 
comparatively  rare.  They  may  be  fibromatous  or  myxomatous, 
single,  multiple,  or  diffused.  They  are  connected,  as  a  rule, 
with  the  fat  about  the  base  of  the  heart,  or  form  upon  its  ex- 
ternal surface.  They  may,  however,  form  independently  of  the 
fat  in  the  heart,  as  elsewhere,  and  may  be  associated  with  any 
other  form  of  new  growth,  or  with  general  fatty  degeneration 
of  the  heart.  Lipomata  may  form  upon  the  endocardium  or 
pericardium,  either  with  a  broad  base  or  pedunculated.  If 
pedunculated  lipomata  form  upon  the  endocardium  they  may 
swing  into  any  of  the  cardiac  cavities,  or  into  the  aortic  orifice 
and  occlude  one  or  more  of  them ;  if  upon  the  pericardial  sur- 
face, they  will  move  freely  within  the  pericardial  space  and  if 
large  enough,  produce  serious  or  fatal  trouble  from  pressure 
alone.  They  may  form  within  the  wall  of  the  heart  and  un- 
dergo fibrous  or  caseous  degeneration.  Any  form  of  new 
growth  may  produce  death  from  pressure  alone,  or  by  inter- 
fering with  the  heart's  action  in  general. 

Lipomata  are  benign  and  rarely,  if  ever,  disappear  spon- 
taneously. They  are  usually  found  after  middle  life,  more  fre- 
quently in  women  than  in  men,  and  do  not  recur  when  removed. 

Banti  and  Handford  (1886)  each  record  a  case  of  primi- 
tive lipoma  of  the  heart,  while  Kolisko  (1887)  observed  two, 


2l6  THE  SURGERY  OF  THE  HEART 

one  of  which  was  congenital.  Pietroni  (1887)  and  Pelroethi 
(1897)  also  contribute  interesting  studies  of  lipomatous 
growths  of  the  heart. 


BIBLIOGRAPHY 

Banti^  G.,  Spcrimcntale,  Firenze,  1886,  LVIII,  237-241. 
Hanford,  H.,  Tr.  Path.  Soc,  London,  1886-87,  XXXVIII, 

108,  112. 
KoLOSKO,  A.,  Med.  Jahrb.,  Wien,  1887,  N.  F.,  II,  135-158; 

I  pi. 
Pietroni^  P.,  Boll.  d.  sez.  d.  cult.  d.  Sc.  Med.,  N.  S.,  Acad.  d. 

fisiocult  di  Siene,  1887,  VI,  101-105. 
Pelroethei,  L.,  Sperimentale,  Arch,  etc.,  biol.     Firenze,  1897, 

LI,  89-98. 


ANGEIOMATA  ( 1 887-1 903 ).—Angeioma  of  the  heart  is 
infrequent.  It  is  formed  of  blood  and  is  known  as  an  erectile 
or  a  vascular  tumor.  It  is  cancerous  when  the  alveolar  spaces 
communicate  with  one  another.  Angeiomata  develop  upon  the 
external  or  internal  surfaces  of  the  heart  indifferently  and  in 
the  same  manner;  they  may  be  interstitial  and  of  any  size  or 
number.  The  projection  may  be  outward  or  inward;  in 
point  of  fact  their  course  is  similar  to  that  of  any  other  kind  of 
cyst.  Angeiomata  may  rupture  in  one  or  all  of  the  chambers  of 
the  heart,  or  into  the  pericardial  sac.  If  they  be  large,  death 
will  ensue,  especially  if  the  rupture  be  into  the  heart's  chamber, 
clots  being  carried  into  the  general  circulation.  If  the  rupt- 
ure of  a  large  tumor  be  external,  the  pressure  alone  may  be 
sufficient  to  produce  death.  Smaller  ones  may  rupture  in 
either  direction  without  causing  dissolution ;  usually,  however, 
fatal  results  ensue  because  of  an  impaired  heart  wall,  resulting 
from  a  pathologic  condition  existing  prior  to,  and  at  the  time 
of  rupture.     Neoplasms  in  any  part  of  the  body  are  more  fre- 


BENIGN   TUMORS  21/ 

qiient  in  women  and  therefore,  cardiac  angeiomata  are  sup- 
posed to  be  so. 

Sussman  (1887)  reports  an  interesting  case,  in  which  he 
found  cardiac  angeioma,  as  does  Mann. 

Schmalts  (1888),  Miura  (1889),  Preisz  (1890),  and  Von 
Etlinger  (1890),  each  record  a  case  of  angeioma  of  the  heart, 
while  Birchoff  (1893)  reports  a  case  of  a  cavernous  angeioma 
of  the  heart,  and  Smith  ( 1894)  records  one  of  the  right  auric- 
ular wall,  terminating  in  rupture. 


BIBLIOGRAPHY 
KiEwiET^  Nederl  Tjdsch,  V.  Geeneeske,  Amsterdam,  i' 

XXII,  550-554- 

SussMANN,  Miinr/z.  Med.  IVoch.,  1887,  XXXIV,  991-1014. 
Mann,  Jahrb.  de  gesellsch.  f.  Nat.  u.  heilk.,  Dresden,  1887-88, 

3-14. 
Schmalts,  D^w^.  Med.  IVoch.,  1888,  XIV,  921-925. 
Miura,  Arch.  f.  Path.  Anat.,  Berlin,  1889,  CXV,  355  ;  i  pi. 
Preiz,  Heit.  z.  Path.  Anat.  u.  Allg.  Path.,  Jena,  1890,  VII, 

245-298;  I  pi. 
Von   Etlinger,  Arch.   f.  Kinderheilk.,  Stuttgart,    1890-91, 

XII,  348-359- 

Birchoff,  Balnitsch  Gaz.  Botkina,  St.  Petersburg,  1893,  IV, 

673-676. 
Smith,  Med.  Rec,  New  York,  1894,  XCVI,  5-9. 
Raw,  Arch.  f.  Anat.,  Berlin,  1898,  CLIII,  22-2^;  i  pi. 


RHABDOMYOMATA. — Rhabdomyoma  is  a  rare  form  of 
primary  myoma  characterized  by  the  presence  of  striated  mus- 
cular fibre.  It  is  found  in  the  muscular  tissue  of  the  heart 
upon  the  endocardial  or  pericardial  surface  or  within  the  car- 
diac walls. 

Rhabdomyoma   is  single   as  a  rule,   but  may  be  multiple. 


2l8  THE  SURGERY  OF  THE  HEART 

and  in  either  event  causes  serious  trouble  by  its  presence,  like 
other  forms  of  new  growth. 


BIBLIOGRAPHY 

Seiffert. — Uber  congent.  Rhabdomyomie  des  herzens. 
\'erhandl.  d.  Deutsche  Patt.  Gesellsch,  Berhn,  1901,  III,  64, 
i.  abb. 


MYXOMATA. — Myxoma  is  a  mucous  tumor  composed  of 
connective  tissue,  gelatinous  in  character,  containing  intercel- 
lular substance  in  which  are  scattered  peculiar  branched,  or 
stellate  cells.  It  attacks  the  epithelium  and  connective  tissue, 
involving  one  or  both,  and  may  be  single  or  multiple,  and  vary 
in  size  and  shape. 

Its  location  may  be  in  any  portion  of  the  heart,  and  it  may 
produce  serious  trouble  from  its  size  or  location,  or  it  may 
rupture  into  the  cardiac  cavities  and  thence  discharge  into  the 
general  circulation,  or  into  the  pericardial  space,  and  so  cause 
death  by  pressure  alone. 

Berteusen  (1893)  reported  a  case  of  myxoma  of  the  left 
auricle,  adding  much  information  as  to  their  formation.  Robin 
(1893)  reported  a  case  of  myxoma  of  the  heart.  His  is 
among  the  earlier  reports  of  this  rare  condition;  not  till  1897 
did  Petroff  report  a  similar  case. 


BIBLIOGRAPHY 

Robin,  A.,  Arch,  de  Med.  Experim.  et  d'arch.  Path.,  Paris, 

1893,  802-806. 
Petroff,  N.,  Balnitsch,  Gaz.  Botkina,  St.  Petersburg,  1897, 

VII,  745-751- 

Berteusen,  Vratch,  St.  Petersburg,  1893,  XIV,  145-181. 


Plate  XXVI. 


X  180. 

Trichina  Spiralis, 

(Encysted  in  Human  Voluntary  Muscle), 


X  180. 
Trichina  Spiralis,  (Free), 


(Chapter  on  Animal  Parasites.) 


BENIGN   TUMORS  219 

POLYPI  (1689-1903). — Polypoid  growths  may  develop 
upon  any  part  of  the  endocardium  or  at  any  point  upon  the  ex- 
ternal surface  of  the  heart.  They  are  benign  when  composed 
of  fibrous  tissue,  and  slow  in  their  development.  When  of 
rapid  growth,  they  are  associated  with  sarcoma  and  myxoma. 
They  are  sometimes  called  oedematous  fibroid,  and  may  have  a 
broad  base,  or  be  pedunculated. 

They  may  become  detached  in  part  or  as  a  whole,  and  when 
upon  the  endocardium  in  such  case  occlude  one  or  more  of  the 
cardiac  orifices  or  enter  the  general  circulation,  or  both,  and 
act  like  an  embolism. 

Polyps  within  the  cardiac  chambers  were  recognized  as 
early  as  1689  by  Pretten  and  by  Rossen  (1693),  Behrena 
(1724)  and  Klotzsah  (1727),  the  last-named  investigator  hav- 
ing found  them  in  a  subject  who  had  succumbed  to  pneumonia. 

The  most  interesting  of  the  earlier  observations,  however, 
were  made  by  Huxham  (1732)  of  polypi,  taken  out  of  the 
hearts  of  several  sailors  arrived  at  Plymouth  from  the  West 
Indies.  Their  development  was  probably  due  to  blood 
changes,  resulting  from  the  habits  of  the  sailors,  and  their  pro- 
longed stay  in  a  tropical  climate.  Nothing  has  since  devel- 
oped to  indicate  anything  of  an  epidemic  nature  in  their  forma- 
tion. Templeman  (1756)  reported  a  polyp  in  the  heart  of  a 
subject  who  had  scirrhous  tumor  of  the  uterus. 

Sherrill  (1820)  gives  a  detailed  report  of  a  polyp  found 
in  the  heart  of  a  child  eight  years  old.  Le  Groux  (1827) 
made  an  exhaustive  research  into  the  causation  and  character 
of  cardiac  polypi.  He  was  followed  by  Barrera  (1829)  who 
failed,  however,  to  add  anything  new  to  the  knowledge  already 
obtained.  Harty  (1830)  ventures  to  speak  of  polypi  of  the 
heart  as  an  idiopathic  affection  and  as  a  cause  of  death.  Za- 
briskie  ( 1835)  reports  a  case  of  polyp  in  the  heart  of  a  woman 
with  death  during  labor. 

Henderson  (1843)  mentions  a  diseased  heart  with  a  globu- 
lar polypus  in  the  right  auricle.    Aran  (1844)  one  in  the  ven- 


220  THE  SURGERY  OF  THE  HEART 

tricle  extending  into  the  pulmonary  artery  and  obstructing  it. 
Harpur  (1845)  reports  a  similar  one.  Fletcher  gives  a  most 
interesting  case  of  this  character  in  which  an  organized  polyp 
of  the  heart  grew  from  the  left  auricle  and  hung  from  the  left 
ventricle,  giving  rise  to  a  peculiar  bruit,  distinctly  audible  some 
yards  from  the  patient.     This  was  verified  by  the  autopsy. 

]McCormick  (1864)  wrote  an  able  essay  on  the  effect  of 
blisters  in  the  formation  of  polypi,  and  McGillivray  (1866) 
described  fibrous  polypi  in  the  right  heart,  accompanied  with 
tricuspid  regurgitation,  in  a  case  of  double  pneumonia. 
Douglas  (1868)  and  Gaskoin  (1869)  each  report  a  polyp  in 
the  left  auricle.  Hill  ( 1875)  reports  a  case  of  cardiac  polypus 
in  connection  with  malaria  and  Ribail  (1883)  one  in  a  case  of 
pulmonary  tuberculosis,  associated  with  parenchymatous  ne- 
phritis. In  the  case  of  Aikins  (1888),  death  was  sudden  from 
a  cardiac  polypus.  Voeleker  (1892)  reported  a  case  of  intra- 
auricular  cardiac  polypi. 


BIBLIOGRAPHY 

Pretten^  Wittenbergse,  1689. 
RossEN,  A.,  Lund  Bat.,  1693. 
Behrena^  Herrn  Geistlichen.     Saml.  v.  Nat.  ii.  Med.  Gesch., 

Leipsic  u.  Budissin,  1724,  XXIII.  307-316. 
Klotzsch,  Erfordise,  1727. 

Grateloup,  De  polypo  cordis  Argentorati,  1731. 
HuxHAM,  J.,  Phil.  Tr.,  1732-44,  London,  1747.  IX,  135. 
Rausch,  De  polypo  cordis  Halse,  Magdeb.,  1741. 
Van  der  Gryp,  De  polypo  cordis  Lngd  Bat.,  1742. 
Templeman,  P.,  Phil.  Tr.,  1743-50,  London,  1756,  \^I,  1020- 

1022. 
Uhlich,  Beobachtung  von  polyposen  concrementen  des  herzen 

allg.     Med.  Am.,  Alten,  1812,  336-341. 
ScHMELCHER,  Dc  polypis  cordis  Landshuti,  1819. 


BENIGN   TUMORS  221 

Sherrill,  H.,  Med.  Reposit.,  New  York,  1820,  n.s.,  V,  302- 

305- 
L'Egroux,  La  Vie,  Paris,  1827. 

Barrera,  Ann.  di  mcd.,  Milano,  1829,  XLIX,  419-446. 
Caron,  Tumeur  polypiforme  developee  dans  I'oreillette  gauche 

et  plongeant  dans  I'orifice  aiiriculo-ventriculaire. 
Harty,  W.,  Dubl.  M.  Tr.,  1830,  n.s.,  I,  218-255. 
Bland,  Memoire  sur  les  concretions  fibrineuses  polypiformes 

dans  les  cavites  du  coeur.     Rev.  Med.  franc,  et  etrang., 

Paris,  1833,  IV,  175,  333. 
Bronc,  Observation  sur  un  signe  diagnostique  particulier  d'une 

concretion  polypeuse  du  coeur.     Jottr.  hehd.  d.  progr.  d. 

sc.  et  inst.  Med.,  Paris,  1834,  I,  422-429. 
Zabriskie,  J.  B.,  Am.  Jour.  Med.  Sc.,  1835,  XVI,  375-379. 
RoETTEKEN,,  Dc  cordis  polypo.    Wirceburgi,  1836. 
Maignien,  Des  polypes  du  coeur.     Strasburg,  1840. 
Lehmann,  De  cordis  polyporum  natura  et  origine.     Berolini, 

1840. 
Perrier,  Observation  de  concretions  polypiformes  ou  poly- 
pes du  coeur.     Rec.  de  Mem.  de  Med.  Mil.,  Paris,  1842, 

LIII,  50-62. 
Henderson,  Loud,  and  Ed  in.  Month.  M.  J.  Sc,  1843,  m' 

808-816. 
Aran,  Arch.  Gen.  de  Med.,  Paris,  1844,  II,  461-466. 
DuNGLisoN,  R.,  Heart    polypus  of  Cycl.     Pract.  M.   (Twee- 
die),  Philadelphia,  1845,  II'  A^9- 
Harpur,  J.,  Boston  Med.  and  Surg.  Jour.,  1845,  XXXII,  377. 
Morrell,  G.  C,  Polypus  of  the  heart.     Nezv  York  Med.  Jour., 

1846,  VI,  373. 
Fredault^  Des  polypes  du  coeur.     Concretions  polypiformes; 

caillots;  recherches  sur  leur  organisation.     Arch.  Ghi.  de 

Med.,  Paris,  1847,  H'  63-71. 
Fletcher,  Prov.  Med.  and  Surg.  Jour.,  London,  1851,  686- 

688. 
MoppEY,  Zur  dianostik  von  Herz  polypen.     IViith.  d.  Vadisch. 

aerztl.  Ver.,  Karlsruhe,  1852,  VI,  113-117. 


222  THE  SURGERY  OF  THE  HEART 

Xeild,  J.  E.,  Polypoid  growth  of  the  heart.     Lancet,  London, 

1852,  II,  548. 
Hudson,  A.,  A  case  of  fibrinous  polypi  of  the  heart.     Dublin 

Hosp.  Gaz.,  i860,  n.s.,  VII,  83. 
McCoRMiCK,  Dublin  Med.  Press,  1864,  II,  312. 
McGiLLiVRAY,  D.,  Canada  Med.  Jour.,  Montreal,  1866,  II,  51- 

56. 
Douglas,  Edin.  Med.  Jour.,  1868,  XIII,  908-916. 
Gaskoin,  Med.  Times  and  Gas.,  London,  1869,  II,  276. 
Hill,  W.  H.,  Indian  Med.  Gaz.,  Calcutta,  1875,  X,  21 1. 
Clarke,  C.  K.,  A  case  of  cardiac  thrombosis  or  polypus  of  the 

heart  occurring  in  connection  with  pneumonia.     Canad. 

Jour.  Med.  Sc.,  Toronto,  1879.  IV,  86. 
RiBAiL,  Prog.  Med.,  Paris,  1883,  XI,  1056. 
AiKiNS,  W.  H.  B.,  Canad.  Pract.,  Toronto,  1888,  XIII,  319. 
VoELEKER,  A.  F.,  Tr.  Path.  Soc.,  London,   1892-93,  XVII, 

31-35- 
Pavlovskava    Traisa   A.).      Symptomatology   and   cases   of 

polypous  neoplasms  of  left  auricle.     Bolnitsch.  Gas.  Bot- 

kina,  St.  Petersburg,  1893,  IV,  721,  753,  782,  797. 
Krumbholz,  Zur  casuistik  der  gesteilten  herzpolypen  und  der 

herzel  threnken.     Ab.  und  Med.  Klin.  Zr.,  Leipsic,  1893, 

328-331. 
Pedunculated  thrombi  of  true  polypi  of  the  heart.  Russk.  Med., 

St.  Petersburg,  1894,  XIX,  125-140. 
Parlowsky,   R.,   Beitrag  zum  studium  der  symptomatologie 

der  neubildungen  des  herzens-polypose ;  neubildungen  des 

linken  vorhofs.     Berlin  IVoch.,  1895,  XXXII,  393-413. 
Packard,  F.  A.,  Specimen  of  cardiac  polypi.     Tr.  Path.  Soc, 

Philadelphia,  1893-95,  1896,  XVII,  85. 
Carton,  J.,  Polype  du  coeur  gauche  avec  endocardite  articu- 

laire;    insuffisance    tricuspide;    pleuresie    concomitante. 

Gaz.  Med.  de  Picardie,  Amiens,  1897,  ^V'  122-124. 
Seiffert,  Ueber  congenitale  rhabdomyome  des  herzens.     Vcr- 

handhing   d.    Dcutsch    Gesellschaft    Pathologie,     Berlin, 

1901,  III,  64;  I  Abb. 


CHAPTER    XVI 
MALIGNANT  TUMORS 

Tumors  of  the  heart  may  be  primary  or  secondary,  malig- 
nant or  benign,  and  slow  or  rapid  in  their  development,  involv- 
ing all  or  any  part  of  the  cardiac  tissue.  There  are  several 
varieties  of  each. 

SAECOMATA  of  the  heart  are  very  infrequent.  They  may 
be  primary  or  secondary.  They  are  composed  of  embryonic 
connective  tissue  with  cells  varying  in  character  and  number, 
and  are  very  vascular,  sometimes  pulsating.  They  seem  to  be 
intimately  associated  with  blood-vessels,  and  are  more  frequent 
in  men  after  the  age  of  forty.  They  are  supposed  to  be  of 
rapid  growth  in  the  heart,  causing  distress  and  death  from 
pressure  alone.  They  may  be  cystic  and  rupture  into  the  cham- 
bers of  the  heart  or  into  the  pericardial  sac  and  cause  death  in 
either  event.  Fibromatous,  diffused,  melanotic,  spindle,  and 
round-celled  varieties  seem  to  attack  the  heart  with  equal  fre- 
quency. 

Historical  (1880-1903). — Gross  (1880)  records  one  of  the 
first  round-celled  sarcomata  of  the  heart,  and  Jacobi  (1881),  a 
fibrosarcoma.  Broadbent  (1881)  records  a  case  of  sarcoma 
of  the  pericardium  and  Liberius  (1883)  one  of  the  same 
character  which  also  involved  the  bronchial  glands.  Loomis 
(1892)  reported  a  diffused  infiltrating  sarcoma  of  the  heart. 
Manero  (1882)  is  the  only  one  to  record  a  case  of  melanoma 
of  the  heart.  Hektoen  (1893)  records  three  specimens  of  me- 
tastatic tumors  of  the  heart;  ist,  a  carcinomatous  nodule,  im- 
planted in  the  myocardium;  2d,  a  sarcoma  of  the  right  ven- 

223 


224  THE  SURGERY  OF  THE  HEART 

tricle;  3d,  a  primary  round-celled  sarcoma  of  the  epicardium. 
Thacher  (1895)  mentions  a  case  of  sarcoma  of  the  heart. 
Leroux  and  Meslay  (1896)  also  record  a  primary  sarcoma, 
and  Lambert's  (1898)  case  was  a  primary  sarcoma  of  the 
heart.  Raw  (1898)  recorded  a  spindled-cell  fibrosarcoma, 
three  inches  in  diameter,  and  adherent  to  the  wall  of  the  right 
auricle. 

BIBLIOGRAPHY 

Gross,  W.  S.,  Tr.  Path.  Soc,  Philadelphia,  1880,  IX,  9—93. 

Jacobi,  a..  Bull.  New  York  Path.  Soc,  1881,  2  s.  I,  91-93. 

Broadbent,  W.  H.,  Tr.  Path.  Soc,  London,  1881,  2,  XXXIII, 
78-81. 

Manero,  E.,  Gac  de  I'Hosp.,  Valencia,  1882. 

LiBERius,  P.  F.,  Med.  Pribow  K.  Mosk.  Sbornikin,  St.  Peters- 
burg, 1883,  Fby  P,  32-45. 

LooMis,  H.  P.,  Med.  Rec,  New  York,  1892,  XLII,  461. 

Hektoen,  L.,  Med.  News,  1893,  LXIII,  571-574. 

Thacher,  J.  S.,  Med.  Rec,  New  York,  1895,  XLVII,  283. 

Leroux  and  Meslay^  Bull.  Soc.  Anat.,  Paris,  1896,  LXXXI, 
680-685. 

Lambert,  A.,  New  York  Med.  Journ.,  1898,  LXVII,  pp.  210, 
212,  230. 

Raw,  Brit.  Med.  Joiirn.,  Oct.  29,  1898. 

Sterling,  W.,  Sarcome  diffus  du  coeur  des  reins  et  de  la  pro- 
state.    Gazette  lek.,  Warszawa,  1901,  XXI,  731-734. 


CARCINOMATA  (1847- 1903). —Scirrhous  and  encepha- 
loid  cancers  of  the  heart  are  rare  and  are  found  more  frequent- 
ly upon  the  right  side.  They  may  be  primary  or  secondary,  usu- 
ally secondary  malignant,  and  they  have  been  found  in  intra- 
uterine life  and  may  occur  at  any  age,  but  are  more  frequent  in 
middle  life.  The  nodules  are  usually  situated  upon  the  surface 
of  the  heart  and  may  not  implicate  cardiac  fibres.  • 


MALIGNANT   TUMORS  22$ 

Carcinoma  is  more  inclined  to  produce  pericarditis  than 
sarcoma  which  is  more  frequent.  About  fifty  per  cent,  are  sec- 
ondary to  disease  in  other  organs  or  tissues.  It  is  supposed  to 
be  more  common  than  tuberculosis  of  the  heart. 

Andral  and  Bayle  were  the  earliest  writers  on  cancer  of  the 
heart.  They  reported  several  such  cases.  Walsche  collected 
twenty-five  cases  of  cancer  of  the  heart,  but,  like  Andral  and 
Bayle,  did  not  attempt  to  classify  them.  The  distinctive  char- 
acteristics of  malignant  growths  were  not  known  until  after 
Virchow  had  made  his  classification.  Until  that  time,  and 
with  a  few  cases  thereafter  reported,  doubt  will  prevail  as  to 
the  true  character  of  the  neoplasm.  However,  they  were 
known  to  be  of  both  primary  and  secondary  origin.  One  must 
of  necessity  refrain  from  attempting  to  classify  those  of  pri- 
mary origin  in  the  heart,  even  many  of  those  of  secondary  ori- 
gin. The  last,  however,  came  before  the  time  of  Virchow, 
who  gave  them  their  identity. 

Ormerod  (1847)  recorded  a  case  of  encephaloid  disease  of 
the  endocardium  and  Hewitt  (1847)  during  the  same  year 
reported  two  remarkable  cases  of  encephaloid  disease  of  the 
heart.  In  the  case  of  Fletcher  (1850)  there  were  copious  de- 
posits of  cancerous  matter  in  the  heart  and  left  pleural  cavity. 
Wilks  ( 1 854-1 85  7)  found  these  masses  in  the  base  of  the  heart. 
Sibley  (1857)  recorded  a  case  of  endocarditis  in  the  right  side 
of  the  heart,  caused  by  small  cancerous  tumors  beneath 
the  endocardium,  with  additional  adhesive  phlebitis.  Fuller 
(1859)  reported  a  case  of  encephaloid  disease  of  the  heart  and 
right  lung,  and  Wilks  found  secondary  cancer  in  the  heart  and 
intestines.  Maxon  (1867)  observed  encephaloid  cancer  of 
the  heart  and  scirrhous  cancer  of  the  thyreoid  gland.  DeCosta 
( 1880)  reported  a  case  of  cancer  of  the  heart  resulting  in  cere- 
bral embolism. 


226  THE  SURGERY  OF  THE  HEART 


BIBLIOGRAPHY 

Ormerod,  E.  L.,  Med.  Chir.,  London,  1847,  XXX,  39-49. 
Hewett,  p.,  Med.  Chir.  Tr.,  London,  1847,  XXX,  1-7. 
Fletcher^  Prov.  Med.  and  Surg.  Jour.,  London,  1850,  551- 

553- 
WiLKS,  Tr.  Path.  Soc.  London,  1854-55,  VI,  112-114. 

AiNSwoRTH,  F.  S.,  Cancerous  disease  of  the  heart.     Boston 

Med.  and  Surg.  Journal,  1855,  LIII,  148. 
Jackson,  Cancerous  disease  of  the  heart.     Ext.  Rec.  Boston 

Soc.  Improve.,  1856,  II,  226. 
Sibley,  S.  W.,  Tr.  Path.  Soc.  London,  1857-58,  IX,  128-130. 
WiLKS,  Tr.  Path.  Soc,  London,  1857-58,  IX,  87. 
Fuller,  H.,  Tr.  Path.  Soc,  London,   1859-60,  XI,  78-80. 

Also  Abstract,  Lancet,  London,  1860-61,  495. 
WiLKS,  Lancet,  London,  1861-62,  p.  254. 
Peacock,  T.  B.,  Cases  of  cancerous  deposits  in  the  heart.     Tr. 

Path.  Soc.     London,  1865,  XVI,  99-120. 
Maxon,  Tr.  Path.  Soc.     London,  1867,  XVIII,  38  to  42. 
Hun,  E.  R.,  Cancer  of  the  heart.     New  York  Medical  Journal, 

1868,  VII,  106-116. 
Peacock,  T.  B.,  Adventitious  product  in  the  heart.     Syst.  Med. 

(Reynolds),  London,  1877,  IV,  165-181. 
DaCosta,  J.  M.,  Philadelphia  Medical  Times,  1878,  VIII,  266. 
Ingram,  T.  D.,  Cancerous  heart  (  ?)  with  dilated  right  ven- 
tricle; sudden  death  with  symptoms  of  angina  pectoris. 

Tr.  Path.  Soc.     Philadelphia,  1878-79,  VIII,  59-64. 
DaCosta,  J.  M.,  Cancer  of  the  heart.     Med.  Gazette,  New 

York,  1880,  VII,  273,  275. 
Cornil,  G.,  Paris,  1902,  p.  124. 
CoRNiL,  G.,  Etude  sur  le  cancer  du  coeur.     Paris,  1902,  No.  283, 

124  p.     ^ 
Cornil,  G.,  Etude  sur  le  cancer  du  coeur,  Paris,  1902,  No.  282 

124  p. 


CHAPTER    XVII 
ANIMAL   PARASITES— PARASITIC   FUNGI— BACILLI 

Echinococcus. — About  three  and  one-half  per  cent,  of  all 
cases  in  man  are  found  in  the  heart  (Cobbald  and  Davaine) .  It 
is  generally  multiple  and  may  be  within  the  myocardium,  or  be- 
neath the  pericardium  or  endocardium  in  the  form  of  a  tumor. 
Sometimes  the  sac  is  pedunculated  and  is  allowed  to  swing 
within  one  or  more  cavities  of  the  heart,  and  even  in  the  greater 
vessels.  It  may  rupture  and  pass  into  the  general  circulatory 
system,  acting  as  emboli.  Rupture  may  also  take  place  into 
the  pericardial  sac. 

Echinococcus  is  the  smallest  tape-worm  known.  It  needs 
to  be  magnified  in  order  that  its  structure  may  be  made  out. 
Except  to  one  trained  in  making  examinations  it  is  very  hard 
to  distinguish  the  Cysticercus  ordinarily  found  in  man,  from 
many  individuals  of  the  dog  tape-worm.  Measly  beef  and 
pork  are  caused  by  cattle  and  hogs  being  infected  with  cysticerci 
which  have  become  encysted.  The  cysts  in  pork  can  be  easily 
seen  with  the  naked  eye.  Corned  beef  very  frequently  is 
measly.  This  condition  can  be  easily  detected  by  allowing  a 
piece  to  dry,  when  the  calcareous  shells  of  the  cysts  may  be  seen 
as  small  white  spots. 

The  heart  may  become  infected  by  carrying  dirty  hands  to 
the  mouth,  or  from  the  cysts  of  meat  being  broken  in  the  mouth 
and  the  cysticerci  penetrating  the  oesophagus  and  thus  entering 
the  heart. 

Historical  (1718-1903). — Price  (1821)  records  a  sudden 
death  in  which  an  hydatid  cyst  was  found  in  the  substance  of 

227 


228  THE   SURGERY   OF  THE   HEART 

the  heart.  Evans  (1832)  records  a  similar  case,  and  WilHams 
(1834)  found  one  in  the  heart  of  a  child.  Vines  (1845) 
found  the  cysts  in  great  numbers,  floating  freely  in  the  cavities 
of  the  heart.  Budd  (1858),  Coote  (1854),  Wilks  (1859), 
Rosi  (1866),  and  Barclay  (1866)  found  them  in  the  lungs,  and 
Budd  discovered  them  in  the  branches  of  the  pulmonary  artery. 
Kelly  and  Maon  each  reported  cases  in  which  there  was  obliter- 
ation of  the  coronary  arteries  from  pressure  of  the  cyst.  Pea- 
cock (1873),  Goodheart  (1876),  and  Guglielani  each  report 
cases.  Goodheart  cured  his  by  aspiration.  This  was  in  1876, 
so  it  can  be  classed  among  the  earlier  operations  upon  the 
heart. 

Arnould  (1881),  Renaul  (1882),  Knight  (1886),  and 
Martin  Durr  ( 1889),  report  cases  of  sudden  death  as  result  of 
rupture  of  the  cyst.  Demantke  (1895),  Knaggs  (1896),  An- 
dreini  (1897),  Guillemand  (1897),  and  Jameson  (1897)  each 
report  cases  of  this  parasite  in  the  heart,  one  of  which  ruptured 
in  the  right  auricle. 

The  presence  of  entozoa  in  the  heart  is  little  credited  at  the 
present  time.  Osborne  (1847)  reported  a  case  in  which  he 
found  worms  in  the  heart  of  a  dog  with  symptoms  of  hydro- 
phobia. Simpson  (1851)  also  reports  having  found  parasites 
in  the  heart  of  a  dog. 

Somerville  made  the  same  observations  and  Morgani,  Du- 
puytren,  and  Trotter  each  report  such  cases. 


BIBLIOGRAPHY 

KoRTHOLT,  Von,  Egeln  odcr  wiirmcr  so  im  Hertzen  einer  Frau 
gefunden  worden.  Sand.  V.  Nat.  W.  Med.  Gesell.,  1717-1S, 
Breslau,  1718-20,  1218-1221. 

Trotter,  Med.  and  Chcm.  Essays,  1795,  p.  123,  case  of  a  blue 
boy. 

Price,  D.,  Med.  Chir.  Tr.  London,  1821,  XI,  274-76. 


Plate  XXVII. 


X  1000. 
OlDIUM. 


X  720. 

Actinomyces. 


(Chapter  on  Parasitic  Fungi.) 


ANIMAL    PARASITES— PARASITIC    FUNGI— BACILLI        229 

Evans,  H.  R.,  Med.  Chir.  Tr.     London,  1832,  XVII,  507-11 ;  i  pi. 
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CI,  p.  139. 
Williams,  W.  H.,  London  Med.  and  Surg.  Jour.,  1834-35,  VI, 

470. 
Vines,  Med.  Times,  1845-46,  XIII,  28. 
Griesinger,    W.,   liber    acephalocysten   am    Herzen.    Arch.    f. 

physiol.  Heilk.,  Stuttgart,  1846,  V,  280-287. 
Osborne,  West.  Jour.  Med.  and  Surg.,  Somerville,   1847,  3  s., 

VIII,  491- 
Ward,  N.,  Acephalocyst  in  the  substance  of  the  heart.     Tr.  Path. 

Soc,  London,  1848-50,  I,  225. 
Moreno,  J.,  Inosperada  aparicion  de  un  estado  de  ansiedad  y 

difficultad  en  la  respiracion,  seguio  de  la  muerte  a  la  hora  y 

media;  autopsia;  quistes,  hidatidicos  en  la  ventriculo  derecho 

del  corazon.     Gaz.  Med.,  Madrid,  1849,  V,  35. 
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185 1,  XVLLL,  283. 
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VI,   114-117;  I  pi. 
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BuDD,  G.,  Med.    Times  and  Gaz.,  London,  1858,  XVII,  54-56. 

Also    Abstr.   Tr.  Path.   Soc,  London,   1858,  XVII,   54-56; 

also  abstr.  Tr.  Path.  Soc,  London,  1858-59,  X,  80-83. 
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de  Paris,  1859,  XXXIV,  59. 
WiLKS,  Tr.  Path.  Soc,  London,  1859-60,  XI,  71. 
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Oesterlen,  O.,  Arch.  j.  Path.  Anat.,  etc.     Berlin,  1868,  XLII, 

404-418;  I   pi. 


230  THE  SURGERY  OF  THE  HEART 

Kelly,  C,  Tr.  Path.  Soc,  London,  1869,  XX,  145-1481. 

Maxon,  W.,  Tr.  Path.  Soc,  London,  1870,  XXI,  99. 

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Med.  Sc,  Philadelphia,  1876,  n.  s.,  LXXII,  395-98. 
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174,  194,  220,  248,  274. 
Knight,  Liverpool  Med.-Chir.  Jour.,  1886,  VI,  231. 
Hadden,  W.  B.,   Cyst  of  the  heart.     Tr.  Path.  Soc.  London, 

1887-88,  XXXIX,  79. 
Martin,  Durr,  Bull.  Soc.  Anat.,  Paris,  1889,  LXIV,  131. 
Demantke,  G.,  Bull.  Soc.  Anat.,  Paris,  1895,  LXX,  122-125. 
Knaggs,  W.  H.  E.,  Lancet,  London,  1896,  I,  29. 
Andreini,  a..  Bull.  Soc.  Rom.  per  gl.  Stud.  Zool.,  Roma,  1897, 

VI,  227-233. 
Guillemand,  B.  J.,  South  African  Med.  Jour.,  Capetown,  1897-98, 

V,  291. 
Jameson,  L,  Australia  Med.  Gaz.,  1897,  XVI,  598. 
Stoenescu,  N.,  Spitalul  Bucuresci,  1898,  XVIII,  169,  173. 
Peacock,  T.  B.,  Tr.  Path  Soc.  London,  1873,  XXIV,  37. 
Miljnikoff-Razvelenkoff,  Med.  Oh.,  Moskow,  1891,  XXXVI, 

259,  262. 
FiRHET,  Acad.  Royal   de   Mdd.  Belgique,  Bruxelles,  1895,  4  s., 

IX,  394-398- 


ANIMAL   PARASITES — PARASITIC    FUNGI— BACH, I,T        23  I 

Railliet  et  Moret,  CompL  Rend.  Soc.  Biol.,  Paris,  1898,  10  s., 

V,  402-404. 
Giordano,  Gazz.  d'osp.,  Milano,  1898,  XIX,  1566-1568. 

Cysticercus  (1852-1903)  is  of  two  forms,  Saginata  and 
Solium.  It  is  more  frequent  in  India  and  England,  but  is 
found  in  all  civilized  countries.  It  is  found  in  the  muscles, 
liver  and  lungs  of  the  ox.  The  urinary  bladder  is  its  most 
frequent  location  in  man.  It  has  also  been  found  in  the  lung, 
liver,  kidney,  eye,  brain,  and  heart  of  man. 

Taenia  Saginata  is  a  yellowish,  soft,  flattened  worm  vary- 
ing in  length  from  one-fortieth  of  an  inch  to  twenty  feet.  The 
great  variation  in  length  is  due  to  the  fact  that  the  worm  grows 
in  length  by  fission,  or  in  segments,  and  these  remain  attached 
to  each  other,  and  continue  to  grow  at  the  head  end  until  they 
are  found  in  a  large  mass,  which,  when  straightened  out  is 
often  very  long.  The  head  is  about  one  twelfth  of  an  inch  in 
diameter,  without  beak  or  booklets  and  has  a  small  proboscis. 
There  is  a  muscular  sucker  in  each  of  the  four  corners  of  the 
head,  and  from  each  sucker  runs  a  water  vascular  canal.  The 
round  opening  in  the  centre  of  the  head  is  surrounded  by  the 
canals  into  which  the  canals  from  the  suckers  open.  From  the 
circular  canal  two  longitudinal  branches  continue,  one  down 
each  side  of  the  various  segments.  (Examine  the  fully  ma- 
tured proglottides,  as  they  are  arranged  in  a  row.  Small  pa- 
pillae with  central  openings  may  be  observed  alternating  irregu- 
larly on  each  side  of  the  ribands,  a  little  below  the  centre  of  the 
segment.  Running  down  each  side  of  the  flattened  segments, 
which  are  square,  or  longer  than  they  are  broad,  is  the  branch 
of  the  water  vascular  canal,  while  at  the  front  part  of  each  seg- 
ment runs  a  transverse  connecting  branch.) 

By  plunging  the  living  worm  into  a  solution  of  carmine,  a 
most  beautiful  injection  of  the  water  vascular  system  may  be 
obtained.  The  uterus  is  very  much  branched,  the  diverticul?e 
dividing  dichotomously.     The  testes  consist  of  a  convoluted 


232  THE  SURGERY  OF  THE  HEART 

tube  placed  in  the  anterior  part  of  the  segment,  from  which 
leads  a  duct  ending  in  a  cirrhus,  or  penis,  which  may,  in  some 
cases,  be  seen  protruding  through  the  genital  pore.  Close  to 
this  is  the  opening  of  the  vagina,  and  near  the  posterior  part  of 
the  segment  are  a  couple  of  vitelline  glands.  Each  strobilus 
consists  of  three  or  four  thousand  segments,  those  sexually 
matured  commencing  at  or  about  the  four  hundred  and  fiftieth 
from  the  head.  The  cystic  form  is  seen  in  beef  as  small  yellow- 
ish spots,  which  are  especially  numerous  in  the  thin  curved 
muscles  of  a  round  of  beef. 

Taenia  Solium. — Taenia  cucurbitina  or  vulgaris  is  the  form 
which  is  seen  most  commonly  in  Germany.  The  cyst  form — 
Cysticercus-cellulosse — occurs  in  pork,  where  it  gives  rise  to 
the  so-called  measly  condition.  A  similar  cystic  form  is  met 
with  more  rarely  in  man,  in  the  subcutaneous  areolar  tissue, 
between  muscles,  and  in  the  eye  and  brain.  As  in  the  taenia 
mediocanellata,  the  strobilus  is  composed  of  head,  neck  and 
proglottides.  The  worm  is  several  feet  in  length  and  consists 
of  about  twelve  hundred  segments.  There  are  four  suckers 
around  the  head,  arranged  below  a  well-marked  proboscis  or 
rostellum.  The  proboscis  is  armed  with  two  rows  of  hooks, 
the  anterior  of  which  is  the  larger ;  but  all  of  them  are  consid- 
erably larger  than  the  booklets  of  the  taenia  echinococcus.  The 
water  vascular  system  near  the  head  is  double,  and  is  similar  to 
that  met  with  in  Taenia  Mediocanellata,  and  may  be  injected  in 
the  same  manner.  The  segments  are  square  or  oblong.  The 
uterus,  or  more  properly  speaking,  the  ovary,  has  a  number  of 
lateral  branches  (seven  or  ten),  which  again  divide,  but  not 
nearly  to  the  same  extent  as  in  Taenia  jMediocanellata.  The 
genital  pores  of  the  cirrus,  which  alternate  regularly,  should 
also  be  examined. 

The  use  of  uncooked  meat,  soiling  of  the  hands  by  work- 
ing or  handling  dirt  in  which  the  fasces  of  human  beings,  do- 
mesticated animals  and  fowls  may  have  been  deposited,  are 
fruitful  sources  of  infection.     Persons  who  have  harbored  the 


ANIMAL    PARASITES-— PARASITIC    FUNGI — BACILLI        233 

mature  form  of  the  tape-worm,  have  been  known  to  infect 
themselves  by  the  hands  coming  in  contact  with  the  anus  in 
sleep,  or  at  other  times,  or  by  searching  in  the  deposits  for  seg- 
ments, etc.  Cysticerci  have  been  known  to  invade  all  parts 
and  organs  of  the  body. 

Cysticercosis  of  the  heart  is  comparatively  rare  but  by  no 
means  unknown,  as  is  shown  by  report  of  cases.  It  is  quite 
probable  that  some  cases  diagnosticated  and  reported  as  hydatid 
cysts  of  the  heart,  have  been  cases  of  cardiac  cysticercosis. 
Lendet  (1852),  Laure  (1869),  Gibbs  (1872),  Frank  (1879), 
Joso  (1883),  Vitto  (1884),  Meljnikoff  (1891),  Firhet 
(1895),  Giordano  (1898),  Railliet  (1898),  and  Moret  and 
Stoneson  all  give  reports  of  having  found  the  cysticercus  in  the 
heart  of  man. 

BIBLIOGRAPHY 

Lendet,  Soc.  de  hioL,  1852,  Paris,  1853,  IV>  141-146;  also  Bull. 

Soc.  Anat.  de  Paris,  1852,  XXVII,  469. 
Laure,  Lyon  Med.,  1869,  II,  386,  389. 
Gibbs,  W.  R.,  Tr.  South  Carolina  Med.  Soc.  Charleston,  1872, 

86-88. 
Frank,  E.,  Allg.  Wien  Med.  Ztg.,  1879,  XXIV,  376. 
Joso,  Gazz.  Med.  de  Nantes,  1883-84,  II,  124. 
ViTTO,  Gior.  internaz.  de  so.  med.,  Napoli,  1884,  No.  VI,  629,  642. 
MiLjNiKOFF,  Razvelenkofj  Med.  Oh.,  Moskow,  1891,  XXXVI,  259- 

62. 
Firhet,  Acad.  Royal,  de  Med.  Belgique,  Bruxelles,  1895,  4  s.,  IX, 

394-398- 
Railliet  et  Moret,  Compt.  Ren.  Soc.  Biol.,  Paris,  1898,  10  s., 

V,  402-404. 
Giordano,  Gazz.  d'osp.,  Milano,  1898,  XIX,  1566-68. 

Trichina  Spiralis — The  presence  of  this  parasite  in  the  car- 
diac tissues  is  rare,  especially  in  the  human  heart.  It  is  a 
nematode,  commonly  found  in  the  pig,  encysted  in  the  muscles 


234  THE  SURGERY  OF  THE  HEART 

of  the  neck,  shoulders,  back  and  diaphragm.  The  female  is 
larger  and  more  numerous  than  the  male  and  when  found  in 
the  heart  is  of  secondary  origin,  having  escaped  through  the 
alimentary  canal,  into  which  the  parasite  has  been  taken  with 
infected  pork. 

Paragonimus  Westermani. — The  distoma  Westermani  is  a 
trematode  found  in  Asia,  but  now  being  carried  to  all  sections 
of  the  world,  attacking  the  stronger  of  mankind.  It  is  found 
in  the  heart,  lungs,  brain,  liver,  and  other  organs  of  man,  and 
animals  in  general,  being  carried  into  the  stomach  with  food 
and  water,  and  into  the  lung  with  air.  It  penetrates  the  tis- 
sues and  finds  its  way  into  those  of  the  cardiac  system.  Nod- 
ules are  formed,  generally  near  the  base  of  the  heart,  and  as  a 
rule  contain  a  male  and  a  female  parasite.  Distoma  Wester- 
mani is  often  confounded  with  tuberculosis,  especially  if  the 
lungs  are  involved. 

PARASITIC  FUNGI.— Mycoses  of  the  heart  constitute  the 
fungoid  neoplasms,  showing  an  abnormal  growth  of  lymphatic 
glands,  caused  by  pathologic  microbes  (bacterial  or  parasitic) 
in  the  organism.  They  may  occupy  a  part  or  all  of  the  endo- 
cardial or  pericardial  surface  of  the  heart,  or  may  be  inter- 
stitial ;  however,  this  is  exceedingly  rare  as  compared  with  the 
other  two  varieties,  which  themselves  are  rare.  The  true 
character  of  the  earlier  cases  reported  has  not  been  well  estab- 
lished. This  is  also  true  of  many  of  the  more  recent  reports. 
Many  of  them  were,  no  doubt,  parasitic,  possibly  cysti- 
cercus,  or  trichina  hydatids  being  more  frequent  and  generally 
known. 

Julia  (1846)  recorded  cases  in  which  he  found  vegetations 
upon  the  valves  and  inner  walls  of  the  heart.  Bertin  (1857) 
found  a  case  in  which  there  were  adhesions  of  the  heart  to  the 
pericardium  as  the  result  of  vegetations.  Blanchez  (1875) 
reports  a  case  of  a  primitive  form  of  vegetation  upon  the  endo- 
cardium. Desjardins-Beaumetz  (1877)  noted  a  case  in  which 
the  vegetations  were  upon  the  endocardium  about  the  orifice  of 


ANIMAL    TARASITES— PARASITIC    FUNfil — BACILLI        235 

the  pulmonary  artery.  Williams  (1884)  reported  vegetations 
upon  the  mitral  valve,  with  multiple  embolisms  and  consecutive 
aneurysmal  dilatation  of  arteries.  Meigs  (1897)  mentions 
fungous  excretions  on  the  valve  of  the  aorta. 

Actinomyces  was  discovered  by  Langenbeck.  It  is  a  vege- 
table parasite,  occasionally  found  in  the  heart.  It  may  be  pri- 
mary or  secondary.  The  infection  of  the  heart  is  usually  from 
the  left  lung,  as  it  is  more  frequently  affected  than  the  right. 
The  nodules  are  threadlike,  pearly  or  yellow,  and  from  one- 
half  to  two  millimetres  in  diameter.  They  are  star-shaped  and 
composed  of  club-shaped  ends.  The  branching,  segemented 
mycelium  is  diagnostic.  It  is  not  so  serious  if  only  the  external 
surface  of  the  heart  is  involved.  The  nodules  undergo  fatty 
degeneration  and  cause  abscesses,  which  may  rupture  into  the 
cardiac  cavities,  or  into  the  pericardial  sac. 

Carnivorous  animals  seem  to  be  immunized  to  this  disease. 
Infection  is  by  eating  and  drinking  food,  and  by  inhalation  of 
air.  Macroscopically  it  can  only  be  diagnosticated  by  the  pres- 
ence of  yellow  seed-like  bodies  which  may  be  seen  by  the  eye, 
and  a  greasy  feel  to  the  sense  of  touch. 

Aspergillus  is  a  vegetable  parasite,  was  discovered  by  Vir- 
chow  in  1856.  There  are  three  varieties:  (a)  Aspergillus 
fumigatus.  (b)  Aspergillus  niger.  (c)  Aspergillus  flavus. 
Either  one  may  be  found  in  any  part  of  the  cardiac  tissue  of 
man  or  beast. 

The  most  dangerous  of  the  three  is  Aspergillus  fumigatus. 
It  is  green  in  color.  The  conidia  are  generally  colorless,  round 
and  smooth,  and  without  a  membrane.  It  grows  best  in  an 
atmosphere  of  thirty-seven  to  forty  degrees,  centigrade. 

Aspergillus  flavus  is  greenish  yellow  in  color.  The  sclero- 
tia  are  very  small  and  black.  It  grows  best  at  about  twenty- 
eight  degrees  centigrade. 

Aspergillus  niger  is  very  malignant,  and  brownish  black  in 
color.  The  fruit  bearers  are  globular,  sterigmata  long  and 
branching;  conidia  round  and  black,  or  nearly  so;  sclerotia 


236  THE   SURGERY   OF   THE    HEART 

brownish,  and  about  the  size  of  a  rape  seed.     Best  temperature 
for  its  growth  is  about  thirty-five  degrees  centigrade. 

Oidium  albicans  is  a  vegetable  parasite  which  has  but  seldom 
been  found  in  the  heart.  It  forms  delicate  horizontal  fila- 
ments, which  are  apparently  homogeneous  in  structure,  and 
from  which  short  articulated  pedicles  take  their  rise.  The  up- 
permost cells  of  these  pedicles  become  expanded  into  oval 
bodies,  which  fall  off,  germinate,  and  become  filaments.  It  is 
generally  found  growing  in  tangled  masses,  like  minute 
bunches  of  mistletoe,  mixed  with  the  debris  of  scattered  spores, 
cells  of  the  leptothrix,  and  epithelial  scales,  but  if  separate 
filaments  are  followed  out,  such  forms  as  these,  which  are  rep- 
resented, may  easily  be  obtained  (Clark). 


BIBLIOGRAPHY 

Julia,  Jour,  de  Med.  de  Lyon,  1846,  X,  405-432. 

Bertin,  Bull.  Soc.  Anat.  de  Paris,  1857,  XXXII,  214. 

NiCAiSE,  Thromboses  de  I'artere  pulmonaire  avec  un  kyste  puru- 
lent du  cceur  et  des  ossifications  de  la  pie-mere.  Bull.  Soc. 
Anat.  de  Paris,  1863,  XXXVIII,  405. 

Jacques,  Cas  d'affection  organique  du  coeur,  d'endocardite  chro- 
nique  avec  vegetations  sur  la  valvule  sigmoide  de  I'aorte. 
Am.  Soc.  d.  Anat.  Path,   de  Bruxcllcs,  1875,  XXVII,  134- 

137- 
Petres,   Note  sur  la  structure  des  vegetations  globuleuses  du 

coeur.     Bull.  Soc.  Anat.  de  Paris,  1875,  127-29. 
Balzer,  Vegetations  globuleuses  du  coeur.     Bull.  Soc.  Anat.  de 

Paris,  1875,  I>  649-652- 
Blachez,    Endocardite    primitive    a    forme    vegetante.     Bull,    et 

mem.  Soc.  Med.  d.  hop.  de  Paris.  1875,  2  s.,  XI,  297. 
Dujardin-Beaumetz,  Bull,  et  mem.  Soc.  Med.  d.  hop.  de  Paris, 

1877-78,  2  s.,  XIV,  147,  152. 
Letulle,  Vegetations  globuleuses  du  coeur,  etc.     Bull.  Soc.  Anat. 

de  Paris,  1880,  LV,  383-388. 


Plate  XX VII [ 


^  / 


\>L  -  ^ 


<     ( 


>      I V 


X  1000. 

Bacillus   QiDEiLXTis   -\Ialignl 


\ 


\ 


^-i 


X  1000. 

Bacillus  TvpiioinLs. 


(Chapter  on  Bacilli.) 


ANIMAL    PARASITES — PARASITIC    FUNGI— BACILLI        237 

Suzanne,  G.,  Retrecissement  aortique  par  vegetations  des  val- 
vules sigmoides.     Jour,  de  Med.  de  Bordeaux,  1884-5,  XIII, 

534-536- 
Williams,  Austria  Medical  Journal,  1884. 
Rendu,  Retrecissement  non-congenitale  de  I'artere  pulmonaire, 

endarterite    vegetante.     Union    Med.,    Paris,     1884,     3    s., 

XXXVII,  257-297. 
CouPLAND,  S.,  Mycosis  cndocardi.     Lancet,  London,  1885,  I,  477. 
Berti,  G.,  Di  una  rarissima  e  forse  unica  vigiatura  congenita  del 

cuore  osservata  in  un   bambino  che  visse  2  mosi.     Bull.  d. 

Soc.  Med.  di  Bologna,  1887,  6  s.,  XX,  145-158;  i  pi. 
Meigs,  Origin  of  disease,  1897,  p.  56. 

Anthrax. — Anthrax  is  a  bacillus  which  has  become  gener- 
ally distributed  over  the  world,  but  it  seldom  affects  man. 

It  has  been  found  in  the  human  heart  but  a  few  times.  It 
was  discovered  by  Davaine  and  Rayer  in  1850.  Koch  discov- 
ered the  spores.  It  infects  by  being  taken  into  the  body  with 
food,  water,  or  air,  or  it  may  do  so  by  coming  in  contact  with 
the  body  in  many  ways.  It  may  be  primary  or  secondary  in 
the  heart.  The  period  of  incubation  is  from  a  few  hours  to 
four  days. 

Bacillus  (Edematis  Maligni. — Bacillus  oedematis  maligni  is  a 
progressive  gangrenous  oedema  and  emphysema  resembling  the 
bacillus  anthracis.  The  colonies  have  a  granular  appearance, 
forming  long  chains,  which  are  often  twisted.  It  may  be  pri- 
mary or  secondary,  but  is  usually  secondary.  It  is  one  of  the 
few  bacilli  found  in  the  heart.  It  attacks  all  forms  of  animal 
life,  and  all  kinds  of  living  tissue. 

This  bacillus  is  found  on  all  serous  surfaces,  internal  or- 
gans being  but  slightly  affected.  It  is  often  associated  with 
the  bacillus  of  tetanus,  and  originates  in  the  fecal  matter  of 
fowls,  garden  earth,  and  filth  in  general. 

Tuberculosis  (1826-1903). — Tuberculosis  may  be  primary 
or   secondary;  more  frequently  secondary.     In  the   form  of 


238  THE  SURGERY  OF  THE  HEART 

nodules,  miliary  abscesses,  or  ulcers,  varying  in  size;  it  may 
invade  the  endocardium,  pericardial  surface,  or  the  muscular 
structures,  in  part  or  as  a  whole.  It  may  occur  in  child- 
hood but  is  more  frequent  between  the  fifteenth  and  thirtieth 
year,  and  is,  as  a  rule,  slow  in  its  development.  It  is  some- 
times associated  with  syphilis. 

Historical. — Macmichael  states  that  he  found  tuberculous 
deposits  in  the  cardiac  cavities,  pericardium,  and  lungs.  Post 
records  a  case  of  pericarditis  with  tuberculous  nodules  in  the 
cardiac  substance.  Hache  mentions  tuberculous  afifections  of 
the  heart.  Gilman  speaks  of  a  case  of  extensive  tuberculiza- 
tion in  the  walls  of  the  heart.  Banks  mentions  a  scrofulous 
tumor  in  the  posterior  wall  of  the  left  ventricle  of  the  heart. 
Gros  records  one  of  tuberculous  cardiac  granulations,  with 
complete  adherence  of  the  pericardium  to  the  heart. 

De  Costa  (i860)  records  a  case  of  tuberculous  disease  of 
the  walls  of  the  heart;  Sherad  ( i860)  mentions  a  similar  case. 
Leyden  ( 1869)  wrote  upon  three  forms  of  cardiac  tuberculosis  : 
(a)  heart,  (b)  muscle,  (c)  endocardium  clots  in  cavities. 

Demme  (1887)  records  a  case  of  primary  tuberculosis  of 
the  heart;  Oliver  (1887)  gives  a  case  of  tuberculosis  of  the 
heart  and  pericardium.  Sumbera  (1889)  mentions  a  case  of 
cardiac  tuberculosis,  following  acute  general  miliary  tuber- 
culosis. Labbi  (1896)  reports  two  cases  of  tuberculous  myo- 
carditis, one  in  a  boy  six  years  of  age,  and  the  other  in  a  girl  of 
four  years.  Sabraze  ( 1899)  reports  a  case  of  tuberculous  dis- 
ease at  the  base  of  the  sigmoid  valve  and  pulmonary  artery. 
Hektoen  (1901)  reports  tuberculous  perimyocarditis  with  a 
tuberculous  aortic  aneurysm  in  a  dog.  Jones  says  that  tuber- 
culosis and  syphilis  are  both  exciting  and  predisposing  causes 
of  muscular  and  valvular  lesions  of  the  heart.  Smith  records 
two  cases  of  tuberculosis  of  the  heart. 


ANIMAL   PARASITES— PARASITIC    FUNGI — BACILLI        239 


BIBLIOGRAPHY 

Macmichael,  London  Med.  and  Phys.  Journal,  1826,  I,  119-121. 
Post,  A.  C,  Pericarditis;  tubercles  in  the  heart.     New  York  Med. 

Jour.,  1830-31,  I,  253-255. 
Hache,  Rap.  de  michon.     Bull.  Soc.  Anat.  de  Paris,  1832,  VII, 

6-19.     Cases,  tuberculous,  degeneration  of  the  liver  and  heart. 

Extensive  follicular  ulceration  of  the  mucous  membrane  of 

the  stomach.     N.  Am.  Arch.  Med.  and  Surg.  Soc,  Baltimore, 

1835,  II,  169-172. 
Oilman,  C.  R.,  New  York  Med.  Gaz.,  1842,  II,  385. 
RosER,  Ein  fall  von  herz  und  pancreas  tuberkelen  und  ein  fall  von 

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240  THE  SURGERY  OF  THE  HEART 

Haberling,  G.,  De  tuberculose,  myocardie,  Britislaviae,  1865. 

Barcellai,  G.,  Osservazione  di  una  tuberculosi  del  cuore.  Uni- 
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Leyden,  Deutsch  Med.  Woch.,  Jan.  9,  1869. 

ScHOEFFELER,  G.  W.,  Ubcr  die  tuberkulose  des  herzfleisches. 
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Peacock,  T.  B.,  Adventitious  products  in  the  heart.  Syst.  Med. 
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Trippier,  R.,  Note  sur  un  fait  contribuant  k  etablir  I'existence  de 
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ANIMAL   PARASITES— PARASITIC   FUNGI — BACILLI        24I 

Hanot,  v.,  Contribution  k  I'etudc  de  I'endocardite  tuberculeuse. 
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Ramond,  F.,  Hypoplasie  cardio-vasculaire  chez  un  tuberculeux. 
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IV,  589-91. 

Brosch,  a.,  Ein  fall  von  herztubcrculose  mit  typischen  "  Weilschen 
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Labbi,  Rev.  mens,  des  Mal.  de  PEnj.,  June,  1896. 


242  THE  SURGERY  OF  THE  HEART 

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Paris,    1897,   LXXII,    101-103. 
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Anat.,  Paris,  1897,  LXXII,  824-826. 
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Gaz.  Botkina,  St.  Petersburg,  1897,  VIII,  11 71,  1219. 
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granulee.     Bull,  et  mem.  Soc.  Med.  d.  Jwp.,  Paris,  1897,  XIV, 

75^759- 
FucHS,  A.,  De  la  tuberculose  du  myocarde,  Paris,  1898. 
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Soc.  de  Med.  de  Nancy,  C-r.  Mem.,  1898-99,  p.  XXVII. 
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809. 
Aguerre,  J.  A.,  Sur  un  cas  d'endocardite  a  bacilles  de  Koch,  chez 

une  tuberculeuse.     Bull,   et  mem.  Soc.  Anat.,   Paris,    1899, 

LXXIV,  434. 
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Heh.  d.  Soc.  Med.  de  Bordeaux,  1899,  XX,  506-509. 
MixiCH.  K.,  Diverticulum  cordis  e  tuberculo  solitario  ortum  Orv'osi 

Hetil.  Budapest,  1899,  XLIII,  668. 
HoiSHOLT,  A.  W.,  A  case  of  large  solitary'  tubercles  of  the  heart. 

Tr.  Med.  Soc.  California,  Monterey,  1899,  XXIX,  202-208. 
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Soc.  d.  Med.  et  Nat.  de  J  essay,  1899,  XIII,  139,  171,  203. 


ANIMAL   PARASITES— PARASITIC    FUNGI— BACILLI        243 

Imerwol,  V.  L.,  tJber  die  bindegcwebe  induration  des  herzfleisches 
(myofibrosi  cordis).     Deut.  Med.  Woch.,  1900,  XXVI,  750,  753. 

MosER,  A.,  Tuberculosis  of  the  heart.  Med.  and  Surg.  Rep.,  Bos- 
ton City  Hospital,  1900,  XI,  194-203. 

Zu  Jeddeloh,  O.,  tJbcr  knotige  tuberkulose  des  herzcns.  Kiel, 
1900. 

EiSENMENGER.  V.,  Zur  kcnntniss  der  tuberkulose  des  herzmuskels. 
Ztchr.  }.  Heilk.,  Wien  und  Leipsic,  1900,  XXI,  2  Heft,  74-92. 

Hektoen,  L.,  Medicine,  Detroit,  1901,  VII,  193-202. 

Jones,  F.  A.,  American  Medicine,  Vol.  I,  No.  11,  p.  183. 

Smith,  W.  M.,  Medical  News,  Nov.  8,  1902,  p.  885. 

Bacillus  Aerogenes  Capsulatus  (Gas  Bacillus) — This  bacillus 
has  been  found  in  the  heart  muscles  of  rabbits  by  Olhmacher, 
who  says  that  it  was  not  found  in  the  smears  of  the  heart's 
blood.  It  was  first  described  by  Welsh,  who  says  that  it  prac- 
tically dominates  the  whole  field  of  pneumatopathology.  It  is 
extremely  virulent  but  dies  at  about  the  end  of  fourteen  days. 

Bacillus  Typhosus. — Typhoid  bacilli  have  recently  been 
found  in  the  heart  of  man,  by  Vincent  (Merek  Medicine,  Feb. 
17,  1892).  They  have  been  found  in  nearly  all  organs  and  tis- 
sues of  the  human  body.  So  far  as  known  they  are  secondary, 
and  the  effect  of  their  presence  in  the  heart  is  but  little  under- 
stood. 

MISCELLANEOUS  BIBLIOGRAPHY 

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244  THE  SURGERY  OF  THE  HEART 

Lannois,  M.,  Sur  quelques  points  de  la  pathologie  et  de  la  phys- 
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No.  392. 

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ditis.    Berlin,  1885. 

Epstein,  A.,  Defects  des  kammerseptums  partieller  defect  des 
vorhofseptums  einmundung  der  beiderseitigen  lungenvenen 
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lebervenenstammes  in  das  linke  herze  rechtslaufige  aorta 
maugel  der  nulz  und  des  grossem  netzes  gemeinschaftliches 
dunn,  und  dickdarmgekrose  nebst  andern  abnormitaten. 
Ztsch  }.  Heilk.,  Prag.,  1886,  VII,  308,  932;  i  pi. 

Letulle,  Note  sur  la  degenerescence  amyloide  des  cellules  muscu- 
laires  du  cceur.     Bull.  Soc.  Anat.,  Paris,  1887,  LXII,  352-355. 

RuMPF,  Uber  das  eanderherz.  Verhandlung  Cong.  Innere  Med., 
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Mann,  M.,  Cortriculare  binatrictum  eine  entwickelungs-geschicht- 
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487-508;  2  pi. 

Knoll,  P.,  tlber  incongruenz  in  der  thatigkeit  der  beiden  herz- 
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handlg.  d.  Phys.-Med.  Desellsch.  zu  Wurzburg,  1890-91; 
nf.  XXIV,  61-103;  I  pi. 

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Heizl,  R.,  August  Wittmanns  freigelegtes  herz,  geschichte  der  op- 
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des  herzens  Arb.  a.  d.  Wed.  Klin.  Inst.  d.  k.  Ludwig-Max- 
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Poitiers,  1890,  IV,  31. 


Plate  XXIX. 


Tpie  Cross  Rkprksents  the  End  of  a  Kangaroo  Ten- 
don Which  Was  Used  to  Ligate  the  Left 

Coronary  Artery  and  Vein. 
(Experiment  on  the  Heart,  No.  3,  page  263.) 


The  Cross  Ria-Ri'Si^NTS  the  End  of  a  Silk  Ligature 

About  the  Anterior  Coronary  Vessels. 

(Experiment  on  the  Heart,  Xo.  6,  page  264.) 


ANIMAL   TARASITES— PARASITIC   FUNGI— BACILLI        245 

CzAPEK,  F.,  Zur   pathologischen  anatomic    der    primarcn    hcrz- 

geschwullste.     Prag.  Med.  Woch.,  1891,  XV,  448-457. 
JuRGENS,  Zur  casuistik  der  primaren  herzgcschwultste.     Berlin. 

Klin.  Woch.,  1891,  XXVIII,  1031-34. 
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Med.  Oslal,  Borcel,  1891,  XIV,  290. 
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1891;  X,  51-66. 
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parenchymateuse  (non  scle reuse).     Arch,  de  Med.  Exper.  et 

d'Anat.  Path.,  Paris,  1891,  III,  776-9. 
Bard  and  Phillippe,  De  la  myocardite  interstitielle  chronique. 

Rev.  de  Med.,  Paris,  1891,  XI,  345-603.     Experimentale  bei- 

trage  zur  kenntniss  der  myomalacia  cordis.     Skandin  Arch.  /. 

Physiol.,  Leipsic,  1892-93,  IV,  1-45;  i  pi. 
ToDESHi,  A.,  Beitrag  zum  studium  der  herz-geschwulste.     Prag. 

Med.  Woch.,  1893,  XVIII,  121-135. 
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schweg,  1894-99;  II,  408. 
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Int.  Roma,  1896,  VII,  11 7-1 55. 
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4,   R-XII,   1027-1041. 
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grandes  scleroses  cardiaques. 
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1897,   VI,   34.     Le    anomalie    anthropologiche    nei    cardio- 

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156. 
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246  THE  SURGERY  OF  THE  HEART 

HocHHAUS  AND  Reinecke,  Ubcr  chronischc  degeneration  des 
herzmuskels.     Deut.  Med.  Woch.,  1899,  XXV,  749-753. 

Vysin,  v.,  On  scleroses  of  the  myocardium.  Casop  lekcesk  v.  Praze, 
1899;  XXXVIII,  773,  793,  813,  838. 

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GENERAL  REFERENCE 

Vel  Rean,  "  Operative  Surgery,"  1856. 

Clark,  "  Disease  of  the  Tongue,"  1873. 

Erichsen's,  "Science  and  Art  of  Surgery,"  1878. 

Holmes's  "  System  of  Surgery,"  1881. 

Gross,  "  System  of  Surgery,"  1882. 

West,  Trans.  Royal  Mcd.-Chir.  Soc,  1883;  (Aspiration 
of  Pericardium  80  times). 

Hamilton,  "  Principles  and  Practice  of  Surgery,"  1886. 

Smith,  Stephen,  "  Operative  Surgery,"  1887. 

Agnew,  "Surgery,"  1889. 

Billroth,  "Surgical  Pathology,"  1891. 

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Warren,  J.  C,  "  Surgical  Pathology,"  1895. 

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Dennis,  "  System  of  Surgery,"  1895. 

Gould's  American  Year  Book  of  Medicine  and  Surgery^ 
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Tillmann's  "  Principles  erf  Surgery,"  1897. 

"Anomalies  and  Curiosities  of  Medicine,"  Gould  and  Pyle, 
1897. 

Stevenson,  "  Wounds  in  War,"  1897. 

Wharton  and  Curtis,  1898. 

Keen,  W.  W.,  "  Surgical  Complications  and  Sequelae  of 
Typhoid  Fever,"  1898. 

Meigs,  "The  Origin  of  Disease,"  1899. 

Esmarch  and  Holwalzig,  1901,  "  Surgical  Technique." 


CHAPTER    XVIII 

EXPERIMENTAL    RESEARCH    ON    THE    HEART    OF 
THE    DOG 

The  experimental  work  contained  in  this  chapter  was  done 
at  the  laboratories  of  the  University  of  Cincinnati  during  July 
and  August,  1901.  There  were  forty-five  dogs  used  in  this 
series  of  experiments,  to  determine  the  effects  of  different 
kinds  of  injuries  to  the  heart,  pericardium  and  diaphragm,  and 
the  results  of  various  surgical  operations  thereon.  Many  valu- 
able deductions  were  made,  but  it  will  require  further  work  by 
surgeons  and  experimenters  to  determine  many  of  the  possi- 
bilities in  surgery  for  injuries  and  diseases  of  the  heart.  This 
work  is,  therefore,  but  a  small  contribution  to  this  most  inter- 
esting subject.  The  author  desires  to  take  this  opportunity  to 
thank  his  assistant.  Dr.  H.  V.  Spargur,  and  student  Charles  T. 
Souther,  for  their  valuable  assistance  in  conducting  these  ex- 
periments. 

Original  Experimental  Surgery 

(1901-2) 

Nothing  indicates  more  clearly  the  lack  of  confidence  in 
surg-ical  intervention  in  lesions  of  the  heart  than  that  the  lat- 
ter  have  been  treated  as  anomalies.  The  best  history  of  the 
surgery  of  the  heart,  accessible  to  the  general  reader,  is  to  be 
found  in  a  work  that  treats  of  anomalies  and  abnormalities. 
They  of  themselves  show  that  the  heart  is  more  susceptible  to  in- 
jury, disease,  and  surgical  operation,  than  is  generally  sup- 
posed. 

247 


248  THE  SURGERY  OF  THE  HEART 

Simple  puncture  with  a  needle  was  at  one  time  thought  to 
lesult  in  instant  death ;  indeed  such  an  idea  generally  prevails  at 
this  time.  Infection  in  animals  is  more  likely  than  in  man, 
because  of  the  great  difficulty  in  making  the  former  sterile  and 
keeping  them  so,  after  they  have  been  operated  upon. 

If  experimental  physiology  and  surgery  have  taught  any- 
thing, it  is  to  reason  by  analogy  from  animal  to  man.  Animal 
experimentation  has  led  the  way  to  more  successful  surgical 
work,  and  it  will  continue  to  do  so.  It  not  only  shows  what 
can  be  done,  but  it  teaches,  by  manipulation  alone,  if  nothing 
more,  how  it  should  be  done. 

There  are  many  diseases  and  many  lesions  which  do  not 
manifest  themselves,  or  cause  symptoms  which  are  readily 
discernible.  In  other  words,  the  particular  lesion  is  wholly  un- 
suspected until  it  has  advanced  far  enough  to  produce  func- 
tional disturbances,  which  are  often  serious.  Then  search  is 
made  for  the  cause.  Then  again,  it  is  possible  to  diagnosti- 
cate certain  diseases  only  by  the  symptoms  caused  by  the  func- 
tional disturbance,  produced  by  the  lesion,  and  not  by  the  lesion 
itself.  The  functional  disturbances,  resulting  from  a  given 
lesion,  are  not  always  the  same.  Pathological  physiology  re- 
ceives only  scant  attention,  or  none  at  all,  in  our  medical 
schools,  yet  it  is  of  the  utmost  importance.  Only  a  few  works 
on  this  subject  are  accessible,  and  these  are  unsatisfactory  in 
some  respects.  Many  questions  of  the  utmost  importance  are 
unsettled.  These  remarks  apply  with  peculiar  force  to  the 
heart.  The  intimate  connection  of  the  function  of  respiration 
with  the  heart,  and  the  disturbance  produced  in  the  functions  of 
the  other,  when  either  heart  or  lung  is  diseased,  is  the  reason 
for  taking  up  both  the  normal  and  pathological  physiology  of 
the  heart. 

Aspiration  of  the  pericardium  should  not  be  attempted, 
owing  to  the  dangerous  consequences,  such  as  injury  to  the 
coronary,  internal  mammary,  and  intercostal  vessels,  and 
puncture  of  the  walls  of  the  heart  itself;  and  also,  the  possibili- 


RESEARCH  ON  THE  HEART  OF  THE  DOG       249 

ties  of  infection  from  the  escape  of  fluid,  through  the  puncture, 
into  the  pleural  cavity  and  mediastinal  space.  The  probabili- 
ties are,  that  many  cases  in  which  fluid  has  been  purported  to 
have  been  aspirated  from  the  pericardium,  that  it  was  con- 
tained within  the  pleural  cavity,  mediastinal  space,  pulmonary 
cyst,  or  abscess,  or  a  pleural  cyst. 

The  heart  is  very  susceptible  to  alkaline  solution,  which 
accelerates  it.  The  absence  of  stomata  in  the  diaphragm 
within  the  pericardium,  tends  to  exclude  fluids  from  the  peri- 
toneal cavity.  The  pleural  fluids  will,  however,  pass  through 
the  pericardium.  In  the  lower  animals  (fish),  the  pericar- 
dium and  diaphragm  are  wanting.  As  they  ascend  in  scale, 
the  pericardium  becomes  more  fully  developed  to  form  the 
pericardial  sac ;  the  same  is  also  true  of  the  diaphragm. 

There  is  no  way  of  determining  whether  or  not  the  heart 
will  absorb  to  any  degree  any  fluid  that  may  be  contained 
within  the  pericardium.  Nor  have  such  observations  been 
made  upon  the  ability  of  the  pericardium  itself  to  do  so.  It 
has,  however,  been  determined  that  the  heart  will  not  with- 
stand a  high  degree  of  pressure,  from  fluid  or  otherwise,  within 
the  pericardial  space.  It  will  stand  a  greater  pressure,  if  the 
pressure  be  gradually  increased,  as  in  the  case  of  pericardial  ef- 
fusion, resulting  from  pericarditis.  It  will,  in  a  normal  state, 
absorb  more  or  less  of  its  exudate ;  and  it  will  probably  have  a 
greater  capacity  to  absorb  in  a  pathological  state. 

Pressure,  from  any  source,  may  be  sufficient  to  force  a  part, 
or  all,  of  the  blood  out  of  the  cavities  of  the  heart.  This  may 
be  gradual  or  sudden,  fatality  resulting  only  when  functional 
circulation  cannot  be  maintained.  The  consequences  are  less 
severe,  and  serious  trouble  is  delayed,  if  the  pressure  is  in- 
creased slowly,  as  by  the  growth  of  new  tissue.  Rapid  press- 
ure is  usually  due  to  change  in  shape  of  the  chest,  from  trauma, 
or  from  concealed  haemorrhage,  within  the  pericardial,  pleural 
or  mediastinal  spaces. 


250  THE  SURGERY  OF  THE  HEART 

Operative  Technics 

Sterilization  of  the  local  area  of  the  dog  is  almost  impos- 
sible. The  area  should  be  shaved  after  the  dog  has  had  a 
thorough  bath,  which  is  difficult  to  give  to  tramp  dogs,  as  they 
are  not  accustomed  to  it.  A  sterile  sheet,  in  w^hich  there  is  a 
hole  large  enough  to  operate  through,  should  cover  the  dog. 
Alcohol  or  turpentine  is  applied  to  the  shaven  surface,  which 
is  then  ready  for  incision.  Ether  should  be  employed  in  all 
cases  for  operation,  and  carried  to  complete  relaxation,  and 
then  chloroform  given  to  produce  death. 

The  incision  should  be  made  longitudinally,  beginning  at 
the  third  or  fourth  rib  on  the  left  side,  and  about  one-third  to 
one-half  inch  from  the  internal  mammary  artery,  and  diverg- 
ing slightly  from  the  sternum  down  to  the  desired  point,  even 
to  the  apex  of  the  heart.  It  may  be  extended  to  the  attachment 
of  the  diaphragm,  and  down  to  the  costal  cartilages.  The  ex- 
ternal soft  tissues,  being  divided,  are  then  reflected  outward, 
great  care  being  taken  not  to  have  the  point  of  the  knife  slip 
into  the  chest  cavity,  as  the  heart,  lungs,  or  arteries  may  be 
injured. 

Divide  the  third,  fourth,  fifth,  sixth,  and  seventh  ribs  if 
necessary.  Great  care  must  be  observed,  in  opening  the  chest, 
that  bone  spiculse  are  not  left  to  lacerate  the  heart  during  its 
pulsations ;  otherwise  serious,  if  not  fatal  laceration  of  its  wall 
might  ensue.  Such  an  accident  must  be  guarded  against  dur- 
ing the  entire  operative  procedure.  Great  care  must  be  taken 
to  avoid  such  an  injury  to  the  pericardium  also.  It  is,  there- 
fore, safer,  completely  to  sever  the  bony  structures  with  a  sharp 
cutting  instrument,  than  to  fracture  them  by  force  or  other- 
wise. The  same  precautions  should  be  observed  in  dealing 
with  the  cartilaginous  structures.  If  necessary,  the  cartilages 
may  be  cut  near  the  left  border  of  the  sternum  and  retracted 
outwards  to  the  right  or  left. 

If  the  mediastinal  space  be  opened,  the  respiratory  motion 


RESEARCH  ON  THE  HEART  OF  THE  DOG       25 1 

of  the  thin  membrane,  that  walls  off  the  right  lung-,  may 
greatly  interfere  with  rapid  work.  It  will  especially  be  so,  if 
over  distention  of  the  right  lung  should  rupture  it.  The  right 
lung  would  then  retract  upon  itself.  It  is,  therefore,  safer  and 
less  difificult  if  that  space  be  not  opened.  The  opening  can, 
however,  be  closed  with  the  hand  of  an  assistant  during  the  en- 
tire operation. 

The  bleeding  in  the  skin  and  muscle  is  seldom  annoying. 
The  intercostal  arteries  usually  cease  to  bleed  after  they  have 
been  exposed  to  the  air,  and  sponge  pressure;  if  not,  they  can 
be  easily  controlled  by  forceps.  The  internal  mammary  once 
wounded,  the  haemorrhage  is  great,  and  troublesome  to  check, 
except  in  one  way,  namely,  by  pulling  the  skin  to  the  right, 
leaving  only  the  costal  cartilage  and  muscles  to  constitute  the 
chest  wall,  then  with  the  finger,  or  a  larger  pair  of  acupressure 
or  artery  forceps,  including  all  the  tissues  between  the  carti- 
lages, just  above  the  wound,  in  the  forceps,  which  is  put  on 
parallel  to  the  long  axis  of  the  costal  cartilage,  or  in  the  trans- 
verse diameter  of  the  chest.  It  may  be  necessary  to  do  this 
above  and  below  the  wound,  as  the  internal  mammary  artery 
may  bleed  a  little  from  below,  the  anastomosis  being  very 
free  with  the  deep  epigastric.  After  the  haemorrhage  has  been 
checked,  it  is  best  to  apply  a  ligature  en  masse,  as  it  saves  time, 
which  is  an  item  with  the  heart  exposed. 

The  first  opening  should  give  good  view  and  room  to 
work;  if  not,  incise  two  inches  to  the  left  in  the  intercostal 
space,  and  cut  the  ribs  transversely  with  a  pair  of  sharp  bone 
forceps,  beginning  at  the  outer  border  of  the  incision,  in  the 
intercostal  space.  If  necessary,  other  ribs  are  divided,  that  a 
flap  sufficiently  large  may  be  turned  back  to  give  ample  room. 

There  is  no  occasion  for  using  gauze,  or  any  kind  of  pack- 
ing in  heart  injuries,  especially  in  pericardial  injuries,  as  bleed- 
ing from  the  pericardium  is  insignificant  except  in  cases  of 
injury  at  the  point  of  attachment  of  the  extreme  base  of  the 
heart;  even  then  experiments  show  that  haemorrhage  from  in- 


252  THE  SURGERY  OF  THE  HEART 

juries  to  it  is  but  slight.  To  secure  beneficial  results  from 
gauze  packing  in  heart  injuries,  it  is  necessary  to  employ  firm 
pressure.  To  do  this  would  interfere  with  the  heart's  action. 
Therefore,  it  would  be  more  injurious  than  beneficial  because 
such  pressure  would  force  the  heart  back  upon  the  posterior 
wall  of  the  thorax. 

If  a  patient  survives  the  immediate  thrust  of  a  stiletto-like 
instrument,  however  small,  the  probabilities  are  that  the  haem- 
orrhage will  be  less  when  the  weapon  is  withdrawn  at  the  end 
of  several  hours,  than  on  its  immediate  withdrawal. 

The  styptic  effect  of  the  metal  as  the  result  of  its  coming 
in  contact  with  blood,  together  with  the  formation  of  clots  and 
the  closing  of  the  opening  resulting  from  the  puncture,  by  al- 
lowing the  weapon  to  remain,  will  be  amply  sufficient  in  a  few 
cases  to  prevent  a  fatal  haemorrhage  on  its  withdrawal. 

The  blood  that  most  resembles  in  constitution  the  blood 
contained  in  the  cavities  of  the  heart,  is  that  found  in  the  cor- 
onary arteries,  which,  like  that  in  the  heart,  coagulates  with 
wonderful  rapidity. 

The  blood,  after  having  made  the  round  in  the  body,  comes 
back  to  the  heart  practically  exhausted  of  oxygen.  It  not  only 
contains  CO2  but  other  chemical  compounds,  formed  by  the 
debris  collected  uniting  with  the  constituents  of  the  blood.  At 
the  same  time  it  contains  more  fibrin,  and  doubtless,  also,  more 
of  the  other  elements  which  add  to  the  coagulability  of  the 
blood,  for  in  its  course  it  has  taken  up  the  material  prepared  by 
the  digestion  process  to  repair  the  wear  and  tear  of  the  body. 

In  all  cases  where  important  blood-vessels  were  punctured, 
the  observers  have  been  impressed  by  the  rapidity  of  coagula- 
tion. It  is  very  probable  that  nature  has  so  arranged,  that  in 
case  of  trauma,  where  there  is  haemorrhage  of  the  more  impor- 
tant organs,  coagulation  shall  be  more  rapid  than  elsewhere, 
thus  preventing  death.  It  seems  probable  that  the  rapidity  of 
coagulation  is  proportionate  to  the  importance  of  the  organ  to 
the  animal  economy. 


RESEARCH  ON  THE  HEART  OF  THE  DOG       253 

Contraction  of  a  lung,  when  the  thorax  is  opened,  will 
cause  congestion  of  the  heart.  The  contraction  of  the  lungs, 
whenever  the  chest  is  opened,  exerts  considerable  pressure  upon 
the  various  pulmonary  blood-vessels  and  thus  forces  a  volume 
of  blood,  equal  to  nearly  the  entire  volume  of  blood  normally 
contained  in  the  lung,  into  the  already  engorged  heart,  thus 
bringing  about  a  congested  condition  of  this  organ. 

Care  should  be  taken  in  operations  upon  the  heart,  lest  un- 
due manipulation  cause  death  from  paralysis  of  the  vagi. 

Having  checked  all  haemorrhage  from  the  chest-wall  incis- 
ion, and  the  wound  being  dry,  lift  up  the  pericardium  with  a 
tenaculum.  Great  care  must  be  taken  not  to  puncture  the  car- 
diac tissue,  or  coronary  artery.  The  tenaculum  should  be  in- 
serted over  the  ventricles,  as  there  is  danger  of  wounding  the 
thinner  auricular  wall. 

The  incision  should  be  made  in  its  longitudinal  diameter. 
This  incision  in  the  pericardium  may  be  extended  to  any  de- 
gree necessary  to  familitate  rapid  work,  and  should  be  done 
by  tearing.  Each  bleeding  vessel  must  be  closed  as  soon  as 
opened.  When  the  pericardium  is  incised,  it  retracts,  and 
owing  to  its  thinness,  is  almost  lost  sight  of.  It  however  can 
be  replaced,  and  sutured  in  position  with  a  moderate  degree  of 
ease.  The  pericardium  normally  is  closely  filled  by  the  heart, 
and  when  the  heart  is  beating,  and  not  even  restrained  by  the 
chest  wall,  its  range  of  movement  is  very  great.  This  must  be 
seen  to  be  appreciated. 

The  pericardial  cavity  is  now  cleared  of  all  clots,  by  one 
sweep  of  the  finger  if  possible.  Gauze  may  be  carefully 
wrapped  around  the  finger,  but  it  is  best  not  to  use  it. 

The  heart  is  gently  grasped  in  the  palm  of  the  left  hand, 
great  care  being  taken  not  to  use  any  more  pressure  than  is 
absolutely  necessary  to  enable  the  needle  to  be  plunged  through 
the  wall  of  the  incision. 

The  heart  can  be  handled  to  a  remarkable  degree  without 
any  appreciable  change  in  beat,  except  the  dilatation  caused  by 


254  THE   SURGERY   OF  THE   HEART 

the  loss  of  the  supporting  sac — the  pericardium.  This  hand- 
hng  of  the  heart  is  safe,  provided  not  too  greatly  prolonged. 
The  loss  of  support  of  the  chest  wall  and,  more  important,  of 
the  closely  fitting  pericardium  cause  a  great  extra  strain  on  the 
myocardium. 

Careful  inspection  of  the  naked  heart  shows  its  great  dis- 
tention, and  when  it  seems,  or  really  is,  paralyzed  by  overdis- 
tention,  holding  together  for  a  moment  the  wound  in  the  chest 
wall  will  cause  the  heart  to  regain  its  normal  action.  The 
operation  may  now  be  continued.  If  necessary,  this  may  be 
repeated  several  times  during  the  operation.  The  operation 
being  finished,  the  heart  is  returned  to  the  pericardial  cavity, 
the  pericardium  now  being  brought  into  position  with  small 
tenacula  and  a  running  suture  of  catgut  placed  in  it. 

As  the  artery  tension  is  not  great  when  the  chest  wall  is 
closed,  a  suture  can  be  used  that  need  not  last  so  long.  The 
pericardium  tends  to  go  back  in  place  after  the  replacement  of 
the  heart.  There  was  a  plastic  pericarditis  in  all  the  autopsies, 
and  the  pericardium  was  adherent  for  a  distance  around  the 
incision  in  the  pericardium  of  from  one-half  to  one  inch. 

In  most  cases  the  pericardium  was  not  sutured,  and  the  re- 
sult was  very  good  as  to  replacement.  So  good,  that  in  any 
case  in  which  there  is  danger  in  prolonging  the  operation,  one 
is  justified  in  allowing  the  pericardium  to  remain  open,  for  the 
closing  of  the  wound  tends  to  keep  the  heart  in  place,  and  keep 
the  pericardium  closed. 

This  same  work  does  not  control  so  well  the  haemorrhage 
in  wounds  of  the  left  ventricle,  as  the  wall  is  very  strong  and 
resilient ;  however,  this  method  is  the  best  and  most  convenient, 
and  it  is  always  easy  to  govern  the  degree  of  pressure,  which 
should  be  only  great  enough  to  prevent  blood  from  coming  out 
(luring  systole.  In  diastole,  the  pressure  should  be  slightly 
relaxed. 

As  to  putting  the  needle  through,  during  systole  or  diastole, 
I  think  that  will  be  forgotten  when  it  comes  to  the  work,  as 


Plate  XXX. 


,41* 


^• 


^4 


1 


Experiment  on  the  Heart,  No.  9,  page  266. 


Experiment  on  the  Heart,  No.  10,  page  266. 
-     Showing  Silk  Sutures  in  Place. 


RESEARCH    ON   THE    HEART   OF   THE    DOG  255 

with  a  heart  bounding  and  changing  position  at  least  one-half 
to  one  inch,  seventy  to  one  hundred  times  a  minute,  we  are 
glad  to  get  a  needle  within  one-quarter  inch  of  the  work 
aimed  at. 

\\^hen  the  auricle  is  opened,  naturally  the  blood  comes  out 
with  considerable  force,  but  this  can  be  entirely  controlled  by 
putting  the  ball  of  the  finger  over  the  opening,  yet  the  force 
does  not  have  to  be  great  enough  to  obliterate  the  auricle,  or 
press  the  walls  in  contact.  The  pressure  can  be  accurately 
gauged  in  this  way,  and  it  controls  the  haemorrhage  almost  per- 
fectly. 

Suturing  the  heart  is  very  essential,  and  should  a  needle  not 
be  ready,  the  finger  can  be  kept  in  place  while  a  well-curved 
needle  is  passed  from  one  side  to  the  other,  under  the  finger. 
The  needle  should  be  long  and  semicircular,  but  not  hea\y. 
Theoretically,  to  insert  the  needle  in  diastole  is  right,  but  it  is 
one  part  of  theory  that  we  lose  sight  of,  in  the  critical  moment, 
and  should  the  heart  cease  to  beat  for  a  few  seconds  to  a  min- 
ute, or  even  two  minutes,  as  it  does,  our  duty  is  to  keep  the  fin- 
ger on  the  heart  wound,  and  close  the  wound  in  the  chest  by 
grabbing  its  edges,  keeping  finger  in  position.  Then,  if  the 
heart  resumes  its  beat,  further  effort  can  be  made  to  close :  if 
not,  the  work  is  done  as  best  it  can  be. 

The  question  whether  to  continue  work  even  though  the 
heart  stops,  is  an  open  one.  On  one  side,  we  have  the  ver}- 
great  advantage  of  a  quiet  tissue  to  work  on.  which  will  be  posi- 
tively frightening  when  it  comes  so  suddenly,  and  on  the  other, 
the  less  chance  or  probable  less  chance  of  resuscitation,  if  we 
keep  the  chest  open.  We  should  choose  the  lesser  evil,  if  we 
can  sometimes  decide  which  really  is  better. 

In  suturing  the  heart's  tissues,  the  organ  should  be  held  as 
securely  as  is  consistent  with  minimum  pressure,  and  the  sutur- 
ing done  as  rapidly  as  possible,  the  knots  being  made  by  an 
assistant. 

Glover's  continuous  suture  is  preferable  to  all  others,  because 


256  THE  SURGERY  OF  THE  HEART 

fewer  and  less  complicated  knots  are  required.  This  is  espe- 
cially desirable  when  silk  is  used,  the  object  being  to  get  rid  of 
knots  by  absorption,  as  quickly  as  possible. 

The  simple  continuous  suture  without  knotting,  except  in 
the  first  and  last  punctures,  would  be  ideal,  but  for  the  great 
danger  of  the  suture  breaking,  and  thus  allowing  reopening  of 
the  wound.  This  is  the  great  danger  in  using  absorbable  or 
non-absorbable  material,  as  it  must,  of  necessity,  be  very  light. 
Both  silk  and  kangaroo  tendon  have  been  used  with  great  satis- 
faction in  suturing  penetrating  and  non-penetrating  wounds  of 
the  heart,  also  for  ligating  the  coronary  arteries  at  various 
points. 

However,  the  preponderance  of  evidence  is  in  favor  of  the 
interrupted  suture,  and  that  it  should  be  twisted  silk,  even 
though  kangaroo  tendon  is  more  absorbable.  Wounds  of  the 
heart  repair  themselves,  as  rapidly  as,  if  not  more  so  than  those 
of  other  tissues,  and  the  pericardial  adhesions  are  proportionate 
to  the  extent  of  injury,  whether  clean  or  infected. 

Interrupted  sutures  therefore  should  be  used,  and  the  needle 
and  silk  should  be  as  small  as  will  render  service.  They  should 
be  about  one-eighth  of  an  inch  apart,  and  taken  deeply  in  the 
tissue.  If  the  cavity  of  the  heart  has  been  opened,  the  needle 
should  be  made  to  pass  through  the  entire  thickness  of  the 
heart's  wall.  If  the  endocardium  has  not  been  punctured,  the 
needle  should  be  made  to  traverse  the  floor  of  the  incision.  The 
strength  of  the  suture  material  should  be  determined  at  time  of 
operation. 

Knotting  of  the  sutures  should  be  firm,  and  their  respective 
ends  about  one-quarter  of  an  inch  in  length.  If  shorter,  the 
constant  action  of  the  heart  may  possibly  untie  them. 

Kangaroo  tendon  has  been  used  in  suturing  muscular  tissue 
of  the  heart,  and  in  ligating  the  coronary  arteries,  with  consid- 
erable satisfaction,  more  especially  in  the  latter.  Its  life  will 
depend  upon  the  size  and  quality — the  greatest  objection  being 
to  its  size.     A  larger  needle  is  required  and  the  punctures  from 


RESEARCH   ON   THE   HEART  OF  THE   DOG  257 

it  must  necessarily  be  larger  than  when  silk  is  employed.    Cat- 
gut offers  the  same  objections. 

It  is  pretty  well  agreed  upon  by  experimenters  that  the 
sutures  should  be  applied  during  systolic  relaxation,  that  the  cut 
edges  may  be  perfectly  coaptated.  However,  Rhen  tied  them 
during  diastole  with  equal  success. 

It  is  not  necessary  to  suture  or  apply  any  kind  of  treatment 
to  some  wounds  of  the  heart,  as  they  will  close  and  recover  spon- 
taneously. It  is  impossible  to  say,  or  determine,  the  size  of 
wounds  necessary  to  be  sutured  or  to  be  let  alone,  except  when 
there  is  continuous  bleeding,  which  can  only  be  determined  by 
opening  the  chest.  It  must  necessarily  require  much  time,  and 
careful  observation  of  many  heart  wounds,  to  determine  the 
necessary  procedure  in  each  individual  case. 

The  probabilities  are  that  punctures,  however  small,  into  the 
left  ventricle  or  auricle,  become  enlarged  with  its  systole,  and 
that  death  results  sooner  or  later  from  haemorrhage  alone.  Not 
so,  however,  with  the  right  ventricle  and  auricle,  the  mortality 
being  less  with  similar  wounds.  Therefore,  one  is  justified  in 
believing  that  sutures  are  less  likely  to  tear  out  in  the  thick 
walls  overlying  the  cavities  of  the  left  heart.  This  statement 
appears  inconsistent.  In  the  more  highly  developed  and  older 
animals  of  mature  ages,  the  heart  will  be  more  likely  to  be 
sutured  successfully. 

The  superficial  vessels  (coronary  arteries  and  veins)  lie  side 
by  side,  and  the  amount  of  haemorrhage,  in  case  of  trauma,  de- 
pends upon  its  distance  from  the  origin  of  those  vessels.  It 
will  depend  also  upon  the  character  of  the  wound. 

Knife  and  needle  wounds,  or  those  of  sharp-edged  weapons, 
bleed  the  most,  and  superficial,  lacerative,  the  least. 

The  closure  of  the  chest  of  animals  is  difficult,  for  the  reason 
that  the  animal  cannot  be  kept  quiet.  Of  course  there  are  sev- 
ered ribs,  and  at  times  these  have  to  be  closed  in  two  places. 

Silk-worm  gut  and  silk  (heavy)  were  used  in  most 
cases,  silk  for  the  bony  wall,  and  intercostal  muscles,  one  suture 


258  THE  SURGERY  OF  THE  HEART 

on  each  side,  or  rather  one  between  each  rib,  the  ribs  being  as 
nearly  approximated  as  possible.  Then  the  muscle,  and  the 
skin,  all  in  one  layer,  were  sutured  with  silk-worm  gut.  As 
before  stated,  the  two  tiers  of  sutures  did  not  come  directly 
above  each  other,  from  the  fact  that  after  the  first  incision  was 
made,  the  outer  flap  was  dissected  up  for  a  distance  of  an  inch, 
and  then  the  wall  opened.  This  puts  the  two  rows  one  inch 
apart,  and  protects  them  from  contamination  by  infection,  and 
also  makes  a  sort  of  valve,  as  in  the  operations  for  colotomy  and 
gastrotomy. 

In  putting  in  the  external  sutures,  they  should  be  close,  and 
extend  down  into  the  intercostal  muscle  under  the  line  of  skin 
incision,  to  add  to  the  security  of  the  wound.  Not  often  was 
there  any  trouble  in  getting  the  wound  closed  well  enough  to 
prevent  the  passage  of  air  into  the  pleural  cavity. 

Drainage  should  be  provided  for  in  the  same  way  as  for 
wounds  in  other  parts  of  the  body,  and  governed  by  the  same 
principles. 

The  dressings  should  be  aseptic,  and  securely  held  in  place 
with  adhesive  plaster,  and  bandages  encircling  the  body,  and 
about  the  shoulders. 

The  post-operative  treatment  requires  that  simple,  nutritious 
food  should  be  prescribed,  with  more  or  less  stimulation,  as  the 
case  may  require.  Alcohol  may  be  given  by  the  stomacli, 
in  the  absence  of  nausea.  If  there  be  nausea,  it  should  be  given 
by  the  rectum.  Artificial  heat  should  be  applied,  if  the  tempera- 
ture becomes  subnormal,  or  if  it  be  otherwise  indicated.  Oxy- 
gen is  indicated,  and  is  probably  the  most  satisfactory  way  of 
stimulating,  when  stimulation  is  demanded. 

Remarks  on  the  Various  Experiments 

In  carrying  on  the  series  of  experiments  the  object  was  to 
induce  as  many  complications  as  possible.  That  this  might  be 
accomplished,    aseptic    principles    were    disregarded,    and    the 


RESEARCH    ON   THE   HEART   OF   THE   DOG  259 

pleural  cavity  many  times  entered.  In  a  few  instances,  clots 
were  allowed  to  remain  in  the  pleural  or  cardial  sac,  and  some- 
times both,  that  their  disposition  might  be  observed.  In  Case 
No.  I,  two  tablespoon fuls  of  blood  were  allowed  to  es- 
cape from  the  coronary  artery  into  the  pericardial  sac,  and 
there  allowed  to  remain.  The  clot  was  afterwards  found 
intact. 

Removal  of  the  pericardium  by  incision  was  done  in  two 
cases.  In  one  death  did  not  ensue ;  dissolution  occurred  in  the 
other  (No.  8)  as  the  result  of  infection  which  might  have  been 
avoided.  In  the  case  of  recovery,  the  heart  was  adherent  to  the 
surrounding  tissues.  In  two  cases,  the  pericardium  was  di- 
vided from  apex  to  base,  with  scissors,  and  allowed  to  retract 
upon  itself,  leaving  the  heart  practically  in  the  same  condition 
as  if  the  pericardium  had  been  removed  by  excision.  Death 
resulted  in  one  of  the  cases. 

In  Case  No.  5,  the  pericardium  was  divided  longitudinally, 
and  sutured  to  the  chest  wall  with  silk.  The  animal  was  killed 
sixteen  days  afterward.  Even  though  this  dog  on  the  third  or 
fourth  day  removed  the  sutures  in  the  chest  wall  with  his 
teeth,  the  wound  was  not  infected.  He  was  allowed  to  lick  the 
wound  until  the  sixteenth  day,  when  he  was  killed.  Autopsy 
revealed  about  one  ounce  of  serous  fluid  in  the  pleural  cavity. 
There  were  adhesions  of  the  pleura,  pericardium,  lungs,  and 
heart  to  one  another,  and  to  the  chest  wall. 

It  has  been  found  that  the  ligation  of  either  of  the  coronary 
arteries  at  any  point  of  their  distribution  will  not  produce  death. 

In  Cases  Nos.  i  and  9,  silk  was  used  for  ligature.  In  Case 
No.  3,  kangaroo  tendon  was  employed,  the  ligature  being  ap- 
plied at  the  origin  of  the  artery.  The  dog's  life  was  taken  in 
the  latter  case,  on  the  fourteenth  day,  and  complete  repair  fol- 
lowing the  ligation  was  found  to  have  taken  place. 

Several  similar  experiments  were  made  with  the  anterior 
coronary  arteries,  with  practically  the  same  results. 

Accidental  puncture  of  one  or  more  branches  of  the  coronary 


26o  THE  SURGERY  OF  THE  HEART 

arteries  occurred  in  three  cases,  more  or  less  complicating  the 
operation. 

In  Case  No.  2  the  posterior  coronary  artery  was  ligated 
about  midway  between  apex  and  base;  the  second  branch,  being 
accidentally  punctured  with  the  needle,  was  also  ligated  at  the 
bifurcation  of  the  main  branches. 

Penetrating  and  non-penetrating  wounds  of  the  heart  were 
made  with  a  bistoury  after  the  chest  had  been  opened,  and  were 
allowed  to  remain  open  from  one  to  ten  minutes,  before  closing 
them  with  suture. 

In  Case  No.  6  two  incisions  were  made  in  the  apex,  over  the 
left  ventricle,  each  being  one-half  inch  long.  The  dog  died  at 
the  end  of  seventy-two  hours.  The  incisions  were  estimated 
to  penetrate  about  one-fourth  the  thickness  of  the  ventricular 
wall.  They  were  shown  at  autopsy  to  have  practically  repaired 
themselves.  The  dog  was  found  to  have  general  tuberculosis, 
which  was  suspected  at  the  time  of  operation,  and  which  was, 
no  doubt,  the  cause  of  his  death,  there  being  no  other  perceptible 
cause. 

In  Case  No.  9,  while  suturing  a  penetrating  wound,  three- 
eighths  of  an  inch  long,  made  in  the  left  ventricle,  the  left 
branch  of  the  anterior  coronary  artery,  which  had  been  acci- 
dentally punctured,  was  included  in  the  last  and  upper  suture. 
The  animal  died  at  the  end  of  seventy-two  hours.  Autopsy  re- 
vealed about  a  pint  of  bloody  fluid  in  the  pleural  cavity,  also  ad- 
hesions between  the  pericardium  and  chest  wall,  and  between 
the  pericardium  and  heart.  The  wound  in  the  heart  was  com- 
pletely and  permanently  closed. 

In  Case  No.  10  a  fine  needle,  armed  with  silk,  was  made  to 
pass  so  as  to  make  four  sutures  closely  approximated  over  the 
left  ventricle,  the  object  being  not  to  perforate  the  endocardium. 

Case  No.  1 1  demonstrates  the  suturing  of  a  non-penetrating 
wound  one  inch  long,  involving  about  half  the  thickness  of  the 
ventricular  wall,  and  in  which  silk  was  used  for  suture.  Com- 
plete suspension  of  respiration  lasted  two  minutes,  but  operation 


RESEARCH   ON   THE   HEART   OF   THE   DOG  261 

was  not  discontinued  during  this  time.  Normal  respiration 
was  re-established  spontaneously.  Death  occurred  seventy-two 
hours  afterward  as  the  result  of  infection  due  to  the  animal  hav- 
ing torn  out  all  the  sutures  in  the  chest  wall.  The  incision  in 
the  heart  had  firmly  united,  the  heart  itself  being  nearly  firm. 

In  a  small  non-penetrating  wound  in  Case  No.  14  in  the  wall 
of  the  left  ventricle  a  continuous  suture  of  silk  was  applied. 
Respiration  ceased,  as  the  pericardium  was  being  opened,  but 
soon  re-established  itself  and  again  ceased  upon  completion  of 
the  last  stitch.  It  was  not  again  re-established.  The  heart  con- 
tinued to  beat  two  minutes  after  the  last  respiration.  If  death 
had  resulted  from  the  puncture  of  one  or  more  cardiac  ganglia, 
the  heart  would  not  have  continued  to  beat  for  two  minutes 
after  the  last  respiration. 

In  Case  No.  17  death  occurred  while  incision  was  being 
made  in  the  left  ventricular  wall.  This  may  have  been  due  to 
injury  to  one  or  more  of  the  automatic  ganglia.  This  is  hardly 
probable ;  at  least  it  has  not  been  proven,  because  death  has  oc- 
curred under  similar  circumstances  without  any  injury  to  the 
heart. 

An  incision  requiring  two  silk  sutures  was  made  in  the  wall 
of  the  left  ventricle  in  Case  No.  18.  These  sutures  were  made 
too  tight,  and  therefore  cut  through  the  muscular  tissues  of  the 
heart,  resulting  in  death. 

Needle  punctures  of  the  heart  were  made  in  several  cases,  in 
various  portions  of  the  organ.  In  one,  eighteen  such  punctures 
were  made  in  the  various  portions  (of  the  heart)  from  apex  to 
base,  the  object  being  to  injure  the  cardiac  ganglia.  In  no  in- 
stance did  death  ensue,  nor  were  the  movements  of  the  heart 
influenced  to  any  noticeable  degree. 

Stimulation  of  the  heart  to  action  after  it  had  ceased  to 
beat,  was  accomplished  several  times  by  rhythmically  compress- 
ing the  apex  of  the  heart  with  the  fingers,  also  by  pricking  the 
apex  of  the  heart  with  a  needle. 

The  most  interesting  of  all  the  experiments  was  in  Case  No. 


262  THE  SURGERY  OF  THE  HEART 

1 6,  in  which  a  non-penetrating  incision  was  made  in  the  left  ex- 
ternal ventricular  wall,  necessitating  the  introduction  of  four 
silk  sutures  to  close  it. 


Record  of  Experiments 

No.  I.  August  6,  1901,  9.45  A.  M. — Incision  made  in  the  chest  wall, 
beginning  in  sixth  intercostal  space;  five  ribs  resected,  pericardium 
divided,  and  the  left  coronary  artery  ligated,  after  being  punctured. 
Two  tablespoonfuls  of  blood  allowed  to  escape  from  the  artery,  and  let 
into  the  pericardial  space,  and  permitted  to  remain  there.  Silk  used 
for  a  ligature.  Chest  walls  closed  with  sutures  of  heavy  silk,  and  in- 
teguments sutured  with  silk-worm  gut.  At  i  P.  M.,  dog  was  in  good 
condition,  drank  water,  and  walked  about. 

Autopsy.  Dog  died  some  time  during  the  night  of  August  6.  He 
was  injected  on  the  following  day  with  formalin.  Post  mortem  made 
August  9  at  2.30  p.  M.  General  peritonitis,  peritonaeum  greatly  con- 
gested, abdominal  cavity  filled  with  a  bloody  serous  effusion;  left  upper 
lobes  of  left  lung  congested;  pericardium  adherent  to  both  chest  wall 
and  heart. 

No.  2.  August  6,  1901,  10.20  A.  M. — Time  of  operation  6  minutes. 
Mixed  fox-terrier,  weight  25  pounds,  age  two  years.  Apex  beat  nor- 
mal; pulse  no. 

Incision  made  two  inches  to  the  left  of  the  median  line,  extending 
from  second  to  eighth  rib.  Pericardium  divided  from  apex  to  base.  In 
passing  a  small  needle  about  the  posterior  coronary  artery  midway  from 
apex  to  base,  the  second  branch  was  accidentally  punctured.  Bleed- 
ing was  profuse,  requiring  Hgation.  The  ligature  was  applied  at  the 
bifurcation  of  the  main  branches.  About  four  ounces  of  blood  escaped 
before  the  ligature  could  be  secured.  Clots  were  taken  out  of  the  peri- 
cardial cavity  three  different  times.  Respiration  ceased  at  the  end  of 
eight  minutes.  Heart,  however,  continued  beating  sixteen  minutes. 
Resorted  to  tracheotomy,  ten  minutes  after  cessation  of  respiration; 
and  various  artificial  methods  were  of  no  avail.  Before  this,  the  oper- 
ator had  to  stop  occasionally  and  hold  chest  opening  closed  with  his 
finger,  as  respiration  was  not  good  at  any  time. 

Autopsy  was  made  immediately.     No  special  cause  of  death  dis- 


Plate  XXXI. 


Experiment  on  the  Heart,  Xo.    ii,  page  266. 


Je> 


r    ^f 


*     ^ 


Experiment  on  the  Heart.   Xo.    12.  page  267. 
Showing  Silk  Sutures  ix  Pl.\ce. 


RESEARCH    ON   THE   HEART   OF   THE   DOG  263 

coverable.  It  was  probably  due  to  paralysis  of  vagi,  the  result  of  manip- 
ulation of  the  thoracic  organs  during  operation. 

No.  3.  August  6,  1901,  2.45  p.  M. — Time  of  operation  eight  min- 
utes. Mixed  spaniel,  weight  25  pounds,  age  one  and  one-half  years, 
well  nourished. 

Incision  made  two  inches  to  left  of  median  line,  from  second  to 
eighth  rib,  cutting  through  the  cartilages.  A  transverse  incision  also 
made  at  the  lower  end  of  seventh  rib.  Left  coronary  artery  ligated  at 
base  with  kangaroo  tendon.  About  one  and  one-half  ounces  of  blood 
escaped  from  the  internal  mammary  and  intercostal  arteries.  This 
blood  flowed  into  the  pleural  cavity,  because  the  pericardium  had  been 
divided.  The  pericardium  was  not  sutured.  Blood  permitted  to  re- 
main in  pleural  cavity,  where  it  soon  clotted.     (Plate  XXIX.) 

Autopsy,  August  20,  1901,  9  a.  m. — Heart,  lungs,  and  sternum 
removed  intact.  Heart  adherent  to  the  line  of  incision  in  the  chest  wall. 
Lobes  of  left  lung  adherent  to  both  heart  and  chest  wall. 

No.  4.  August  6,  1901,  4  p.  M. — Mixed  bull,  weight  20  pounds, 
age  one  and  one-half  years,  general  condition  at  time  of  operation,  good. 

Chest  wall  incised  two  inches  to  the  left  of  median  line,  from  second 
to  seventh  rib.  Pericardium  divided  from  apex  to  base.  A  puncture 
one-eighth  inch  wide  made  with  a  bistoury  in  the  wall  of  the  heart,  over 
lower  end  of  the  left  ventricle.  Immediately  on  withdrawal  of  the  knife> 
blood  spurted  out  with  great  force.  The  force  was  so  great  that  the 
blood  was  thrown  a  distance  of  twenty  feet.  This  prevented  further 
operative  procedure.     Heart  ceased  beating  at  the  end  of  four  minutes. 

Autopsy  was  made  at  once.  Examination  of  the  heart  showed  that 
the  forcible  expulsion  of  blood  enlarged  puncture  in  the  wall  by  the 
bistoury,  also  shght  lacerations  to  the  right  of  the  puncture,  made  by 
the  forceps  in  an  attempt  to  control  the  haemorrhage.  All  organs  were 
found  to  be  normal. 

No.  5.  August  15,  1901,  1.30  p.  M. — A  young  street  dog,  half  pointer 
(liver  colored),  healthy,  but  emaciated,  weight  25  pounds,  age  nine 
months,  took  ancesthetic  very  hard. 

Incised  fourth,  fifth,  and  sixth  ribs.  Pericardium  divided  and 
sutured  to  chest  wall  with  silk,  and  silk-worm  gut  used  to  close  chest 
wall. 

Autopsy,  August  31,  1901,  9  a.  m.  External  sutures  had  either 
broken  or  were  gnawed,  on  the  third  or  fourth  day  following  operation, 


264  THE  SURGERY  OF  THE  HEART 

At  the  autopsy,  external  wound,  though  open,  was  clean  and  without 
infection,  although  in  the  case  of  all  the  other  dogs,  where  the  external 
sutures  gave  way,  death  occurred  in  a  few  days  from  infection.  The 
incision  dividing  the  ribs,  etc.,  had  healed  so  perfectly  that  it  was  with 
the  utmost  difficulty  that  the  line  of  union  could  be  discovered.  About 
one  ounce  of  serous  fluid  in  pleural  cavity ;  but  all  thoracic  organs  were 
in  a  good  condition.  There  had  probably  been  a  great  amount  of  the 
fluid  absorbed.  The  fluid  found  would  have  been  absorbed  in  a  few 
days.  Adhesion  of  the  pleura,  pericardium,  lungs,  and  heart  to  one 
another  and  to  the  chest  wall. 

No.  6.  August  17,  1901,  10  A.  M. — A  brown  spaniel  bitch,  about  one 
year  old,  weight  20  pounds.     She  was  tuberculous. 

Four  ribs  incised.  A  slit  one  and  one-half  inches  long  made  in 
pericardium.  The  wall  of  the  heart  slightly  scarred  at  the  base  over 
left  ventricle.  Pericardium  was  not  sutured.  Chest  wall  closed  with 
sutures  of  heavy  silk.  Integuments  sutured,  partly  with  silk-worm  gut, 
and  partly  with  silk,  because  the  operator  ran  short  of  silk-worm  gut. 

Autopsy.  Dog  died  August  20,  1901,  at  10  a.  m.  Post  mortem 
was  made  at  once.  Dog  was  found  to  have  been  in  an  advanced  state 
of  pulmonary  tuberculosis.  Death  due  to  infection.  Pus  about  peri- 
cardium.    (Plate  XXIX.) 

No.  7.  August  20,  1901,  8.30  A.  M. — Water  spaniel,  about  two  years 
old,  weighing  about  25  pounds. 

Operator,  in  making  the  incision  through  the  chest  wall,  began  too 
near  the  median  line,  and  thus  accidentally  severed  the  internal  mam- 
mary artery.  Further  operative  procedure  had  to  be  suspended,  in 
order  to  secure  this  artery.  A  silk  ligature  was  applied  transversely  in 
the  intercostal  space,  next  above  the  one  where  the  cut  in  the  artery 
was  made.  (This  accident  served  as  a  caution  to  those  present.  In  all 
operations  involving  the  incision  of  the  chest  wall,  it  is  safer  to  cut  too 
near  the  spine,  than  too  near  the  sternum.  In  other  words,  make  the 
incision  as  far  from  the  sternum  as  possible.) 

Respiration  ceased  at  this  point.  The  suspension  lasted  over  two 
minutes.  Tongue  was  cyanotic,  heart  beat  in  time  and  energy  reduced 
50  per  cent.  No  attempt  was  made  at  artificial  respiration.  The  only 
thing  done  was  to  hold  the  chest  oi)cning  shut  with  the  fingers.  Respira- 
tion finally  became  normal,  and  operation  continued.  The  pericardium 
was  incised  one  and  one-fourth  inches  over  and  below  the  origin  of  left 


RESEARCH    ON   THE   HEART   OF   THE   DOG  265 

coronary  artery.  One  branch  of  this  artery  was  accidentally  punctured 
with  a  tenaculum,  in  lifting  up  the  pericardium,  causing  profuse  haemor- 
rhage. Condition  of  dog  precluded  further  operative  measures.  A 
clot  was  allowed  to  form  in  order  to  stop  the  bleeding.  Two  or  three 
drams  of  blood,  which  entered  the  pleural  cavity,  were  allowed  to  remain. 
Chest  wall  sutured  with  silk,  and  integuments  closed  with  sutures  of 
silk-worm  gut. 

Autopsy.  Dog  died  suddenly  at  12.15  P-  ^-y  August  21.  He  had 
been  walking  around  during  the  morning,  but  was  not  in  very  good  con- 
dition. He  had  been  lying  down,  got  up,  staggered  five  or  six  feet,  and 
fell  dead.  Post  mortem  held  immediately.  One-half  pint  of  fluid  in 
left  pleural  cavity.  No  clots  in  the  pericardial  space.  Pleural  cavity 
was  tilled  with  clots  of  blood,  as  was  also  the  heart.  A  fibrous  clot  closed 
the  incision  in  the  pericardium,  thus  hermetically  sealing  it.  Ligature 
about  left  coronary  artery  intact  and  covered  by  fibrous  exudate.  Left 
lung  greatly  congested,  but  not  pneumonitic.  Lobes  of  left  lung  adher- 
ent to  the  pericardium.  Slight  adhesive  exudations  connected  heart 
and  lungs  with  the  anterior  thoracic  wall.  Clot,  forming  the  adhesion 
to  the  pericardium,  was  accidentally  removed  at  the  autopsy.  The 
right  margin  of  the  incision  in  the  pericardium  was  inverted.  Evidences 
of  infective  pleurisy.  The  blood  permitted  to  remain  in  the  pericardial 
and  pleural  cavity  had  been  partly  absorbed.  The  effusions  present 
were  no  doubt  pleuritic.     Death,  perhaps,  due  to  infection. 

No.  8.  August  20,  1901,  10  A.  M. — Terrier  (Scotch),  weight  20 
pounds,  age  one  year. 

Incised  chest  wall,  two  inches  to  the  left  of  the  median  line.  Re- 
moved pericardium  by  a  circular  incision.  Respiration  ceased  at  this 
point,  remained  suspended  ninety  seconds.  There  was  no  bleeding 
from  the  pericardium. 

Autopsy.  Dog  died  some  time  during  the  night  of  August  22  (death 
probably  occurred  about  12  o'clock,  August  21-22).  Post  mortem 
II  A.  M.,  August  22.  About  eight  ounces  of  fluid  in  left  pleural  cavity, 
evidently  from  the  pericardium.  The  fluid  was  covered  by  more  or 
less  blood,  but  was  not  purulent.  A  tough  fibrous  exudate  covered  the 
exposed  surface  of  the  heart  (that  portion  devoid  of  pericardium).  Ad- 
hesions connected  the  left  lung  to  the  chest  wall,  and  the  heart  to  the 
remnant  of  pericardium.  Left  lung  partially  collapsed,  and  superior 
lobe  congested. 


266  THE  SURGERY  OF  THE  HEART 

No.  9.  August  20,  1901,  10  A.  M. — White  dog,  weight  25  pounds, 
age  two  years. 

A  longitudinal  incision  was  made  in  the  pericardium,  which  was 
then  sutured  through  the  chest  wall.  A  very  fine  needle,  armed  with 
silk,  was  used  in  making  three  punctures  through  the  walls  of  the  heart, 
into  the  left  ventricle.  On  the  withdrawal  of  the  needle  after  the  last, 
an  upper  puncture,  the  coronary  artery  was  accidentally  punctured. 
The  sutures  were  made  taut.  The  left  branch  of  the  anterior  coronary 
artery  was  included  in  the  last  and  upper  suture.  Sutures  were  made 
with  both  silk  and  silk-worm  gut. 

Autopsy.  Dog  died  6.30  A.  M.,  August  22.  Post  mortem  at  10  A.  M., 
August  23.  Death  due  to  general  infection.  A  pint  of  bloody  fluid  in 
pleural  cavity.  Adhesions  between  the  pericardium  and  chest  wall, 
and  between  the  pericardium  and  heart.  Adhesions,  formed  of  fibrous 
bands,  connected  the  lungs  also  with  both  chest  wall  and  pericardium. 
The  adhesions  of  pericardium  were  exceedingly  intimate.  Stitch 
abscesses  in  both  rows  of  sutures,  i.e.,  those  closing  chest  wall 
and  those  closing  the  integuments.  Greenish  pus  filled  each  stitch 
hole.  Heart,  lungs,  pleura,  and  pericardium  covered  with  muco 
purulent  exudate.  Even  the  diaphragm  was  covered  with  a  similar 
exudation.     (Plate  XXX.) 

No.  10.  August  20,  1901,  2  P.M. — Shepherd  dog,  weight  25  pounds, 
age  two  years. 

Pericardium  incised;  heart  punctured  with  a  fine  needle,  armed 
with  fine  silk.  Four  sutures  were  then  placed  in  the  external  surface 
of  the  heart,  over  the  left  ventricle.  Chest  wall  closed  with  silk,  integu- 
ments with  silk-worm  gut.     (Plate  XXX.) 

Autopsy.  Dog  died  6.30  A.  m.,  August  24.  Post  mortem  2  p.  m. 
same  day.  Death  from  infection.  Fluid  in  pleural  cavity.  Effusion 
of  blood  into  the  contiguous  cutaneous  structures.  Adhesions  con- 
nected pericardium  to  the  pleura  and  both  to  the  chest  wall. 

No.  II.  August  20,  1901,  2.30  p.  M. — Shepherd  dog,  female,  weight 
50  to  60  pounds,  age  two  to  three  years. 

Pericardium  incised  about  one  inch.  The  heart  itself  was  incised 
over  the  left  ventricle.  Cut  about  one  and  one-half  inches  long  through 
the  wall  (non-y)enetrating).  Closed  incision  in  the  heart's  wall  with 
sutures  (interrupted)  of  silk.  Chest  wall  sutured  with  silk,  and  the 
integuments  with   silk-worm  gut.     Respiration  ceased,  but  operation 


RESEARCH  ON  THE  HEART  OF  THE  DOG       267 

was  not  suspended.  Suspension  of  respiration  lasted  fully  two  minutes, 
then  normal  respiration  was  restored  spontaneously. 

Autopsy.  Death  occurred  8  A.  M.,  August  23.  Post  mortem  2  p.  m., 
same  day.  Sutures  in  chest  wall  had  been  torn  loose.  Infiltration  of 
blood  into  the  contiguous  cutaneous  structures,  two  ounces,  at  the  very 
least,  in  a  clotted  condition. 

External  sutures  had  rotted  away.  Incision  through  the  integu- 
ments filled  with  a  foul,  ill-smelling,  greenish-colored  pus.  Pleural 
cavity  held  about  a  quart  of  dark  red  fluid.  Part  of  pericardium  had 
sloughed  away;  the  remainder  was  closely  adherent  to  the  heart  and 
covered  with  a  mucopurulent  exudate.  Adhesions  connected  heart, 
pericardium,  pleura,  and  lungs  to  one  another,  and  to  the  chest  walls. 
Incision  in  the  wall  of  the  heart  closely  and  firmly  approximated,  and 
union  nearly  accomplished.  Infection  of  contents  of  the  thoracic 
cavity,  general.  The  material  forming  the  adhesion,  on  visual  inspection 
appeared  to  be  formed  of  fibrous  tissue,  held  together  by  half-formed 
connective  tissue.  The  parietal  pleura,  where  immediately  attached  to 
the  chest  wall,  was  very  much  thickened  by  a  mucopurulent  deposit 
on  its  surfaces,  but  more  especially  by  an  infiltration  that  presented  the 
appearance  of  clotted  blood.  All  the  thoracic  vessels,  except  the 
bronchial,  were  extraordinarily  hard  and  firm  when  removed  from  the 
chest  cavity.  They  felt  as  if  they  had  been  hardened  in  alcohol  three 
or  four  days.     (Plate  XXXI.) 

No.  12.  August  20,  1901,  3  P.  M. — A  black  cur  dog,  about  six 
months  old,  weight,  15  pounds. 

Dog  was  tuberculous.  Chest  wall  opened  and  pericardium  divided. 
At  this  stage  of  the  operation  the  coronary  artery  was  accidentally  punc- 
tured. Operation  suspended  to  secure  the  bleeding  vessel.  Both  the  cor- 
onary artery  and  the  coronary  vein  were  included  in  the  ligature  applied. 
The  dog's  condition  being  so  critical,  nothing  more  was  done.  Chest  wall 
closed  with  silk  sutures  and  the  integuments  with  silk-worm  gut. 

Autopsy.  Dog  died  August  24,  1901,  6.30  a.  m.  Post  mortem 
2  p.  M.,  same  date.  General  infection.  A  bloody,  serous  fluid  in  the 
pleural  and  pericardial  spaces.  The  adjacent  cutaneous  structures 
infiltrated  with  an  exudate  resembling  clotted  blood.  Adhesions  con- 
nected pericardium  to  the  heart  and  pleura,  and  the  latter  to  the  chest 
wall.  These  adhesions  consisted  of  white,  tough,  fibrous  bands.  The 
incision  was  filled  with  foul,  greenish  pus.     (Plate  XXXI.) 


268  THE  SURGERY  OF  THE  HEART 

No.  13.  August  20,  iqoi,  3.15  p.  m.— A  young  fox-terrier,  age  one 
year,  weight  12  pounds. 

Chest  cavity  opened  and  left  lung  excised.  Chest  closed  with  silk 
sutures;  integuments  closed  with  silk- worm  gut.  Lung  stump  sutured 
with  gut. 

Autopsy,  August  29,  1901,  2.30  p.  m.  Dog  killed  with  chloroform, 
recovery  had  been  rapid  and  uneventful,  and  dog  had  been  up  and 
around,  manifesting  a  lively  interest  in  the  work  in  the  laboratory. 
Evidently  he  had  been  a  pet,  for  he  was  very  affectionate,  and  solicited 
caresses  from  the  operator  at  each  visit  to  the  laboratory.  When  chest 
cavity  was  opened  all  the  organs  were  found  to  be  in  good  condition. 
Evidences  of  recent  congestion  of  the  lungs,  adhesions  to  chest  wall.  A 
httle  fluid  in  the  pleural  cavity,  but  there  were  no  signs  of  infection;  a 
few  days,  probably,  would  have  seen  the  disappearance  of  the  last  vestige 
of  fluid  by  absorption.  There  had  been  also  some  infiltration  of  the 
cutaneous  structures,  but  at  time  of  autopsy  it  had  been  about  all  ab- 
sorbed. 

No.  14.  August  21,  1901,  10  A.  M. — A  cur  dog,  about  half  pug, 
weight  18  pounds,  age  two  years. 

Chest  cavity  opened,  and  pericardium  divided.  An  incision,  about 
one-tenth  inch  in  depth,  made  in  the  wall  of  the  left  ventricle.  This 
incision  was  closed  with  a  continuous  suture  of  silk.  Respiration  ceased 
as  the  pericardium  was  being  divided,  but  it  began  again  just  as  the 
last  stitch  was  being  placed;  the  dog  died.  Death  was  probably  due 
to  chest  cavity  being  kept  open  too  long,  or  to  one  of  the  special  ganglia 
in  the  walls  of  the  heart  being  pierced  by  the  needle  in  making  the 
puncture  for  the  last  stitch.  The  operator  punctured  the  heart's  wall 
deeper  than  he  intended.  Heart  continued  beating  fully  two  minutes 
after  respiration  had  ceased. 

No.  15.  August  21,  1901,  10  A.  M. — Cur  puppy,  three  months  old, 
weight  8  pounds. 

Anaesthetized  and  throat  cut.  The  puppy  was  not  old  enough  for 
this  series  of  experiments,  and  in  order  to  compare  a  puppy's  heart  and 
lungs  with  the  adult  organs,  was  thus  sacrificed.  The  thorax  saved 
for  examination  and  comparison.  Observations  were  made  of  his 
appendix.  This  was  very  large,  much  larger  than  those  of  adult  dogs 
weighing  fifty  or  sixty  pounds.  There  was  nothing  abnormal  in  this. 
It  but  illustrated  the  law  that  among  the  higher  orders  of  the  carnivorous 


RESEARCH   ON   THE   HEART   OF  THE   DOG  269 

quadrupeds  and  also  of  the  still  higher  classes,  the  appendix  at  an  early 
stage  of  existence  is  much  larger  relatively  than  in  the  adult.  Among 
some  animals  this  condition  is  found  in  the  foetus,  in  others,  a  short 
time  after  birth.  It  is  not  only  relatively,  but  even  absolutely  much 
larger  in  early  life,  in  some  classes,  than  in  adult  life.  This  law  holds 
good  for  men,  too. 

No.  16.  August  21,  1901,  2  p.  M. — A  very  fat,  black  mongrel,  age 
four  years.     Weight,  50  pounds. 

Chest  cavity  opened  and  pericardium  divided.  An  incision  one- 
half  inch  long  was  made  in  the  external  wall  of  the  left  ventricle.  In- 
cision in  heart's  wall  closed  with  four  sutures  of  silk.  At  this  stage  of 
the  operation  respiration  ceased.  Muzzle  was  taken  off  (cone  for  ap- 
plying the  anaesthetic  had  been  withdrawn  about  the  time  the  operator 
began  to  suture).  The  operator  held  the  opening  in  the  chest  cavity 
closed  with  both  hands.  An  assistant  kneaded  the  abdomen,  in  an 
effort  to  restore  respiration.  At  the  end  of  the  first  minute  the  operator 
introduced  one  hand  into  the  thoracic  cavity,  still  holding  chest  opening 
closed  with  the  other  hand,  and  stimulated  the  heart  by  pinching  the 
apex.  After  a  time  the  dog  took  a  deep,  labored  inspiration.  Then 
respiration  was  suspended  again,  again  a  few  deep  labored  inspirations, 
then  suspension  for  a  considerable  interval.  This  procedure  continued 
for  several  minutes.  There  would  be  several  deep  labored  inspirations 
at  comparatively  short  intervals  of  time,  then  inspirations  would  be 
single,  with  a  longer  interval  of  time  after  each  respiration,  then  a  series 
of  labored  respirations  at  shorter  intervals  of  time  after  each  inspiration. 
This  alternation  of  single,  deep-labored  inspiration  at  considerable 
intervals,  followed  by  a  series  of  several  inspirations  not  quite  so  labored, 
and  at  shorter  intervals  after  each  inspiration,  continued  until  the  dog 
regained  normal  respiration.  The  operator,  in  stimulating  the  dog's 
heart,  observed,  and  called  the  attention  of  his  assistants  to  it  also,  that 
the  heart  began  beating  at  the  end  of  each  inspiration.  There  were 
three  beats  of  the  heart  after  each  inspiration.  The  movements  of 
the  heart  ceased  with  the  suspension  of  respiration.  After  each 
labored  inspiration  the  heart  would  beat  three  times,  but  would 
be  absolutely  motionless  in  the  interval  between  inspirations.  The 
heart's  movements  were  completely  suspended  three  and  one-quarter 
minutes.  Respiration  was  suspended  this  length  of  time,  and  the 
heart  did  not  beat  until  after  the  first  inspiration.     It  took  about  three 


2^0  THE   SURGERY   OF  THE   HEART 

minutes  after  the  first  deep-labored  inspiration  for  the  dog  to  regain 
normal  inspiration.  In  no  case  when  suspension  of  respiration  occurred 
in  this  series  of  experiments  were  drugs  given  subcutaneously  or  other- 
wise to  promote  the  heart's  action.  Neither  was  resort  made  to  trans- 
fusion, nor  any  other  artificial  means  employed  to  stimulate  the  heart. 

Autopsy.  Dog  died  12  m.,  August  24,  1901,  and  post  mortem  made 
the  same  date  at  2  p.  M.  Infection  general.  A  quart  of  bloody  fluid 
in  the  pleural  cavity.  Sutures  in  both  the  chest  wall  and  cutaneous 
structures  had  rotted  away.  Pericardium,  heart,  pleura,  and  lung  were 
adherent  one  to  the  other,  and  to  the  chest  wall.     (Plate  XXXII.) 

No.  17.  August  21,  1901,  2.25  p.  M. — A  brown  spaniel  bitch,  two 
years  old,  weighing  30  pounds. 

Chest  cavity  opened  and  pericardium  divided.  The  external  wall 
of  the  left  ventricle  was  incised.  After  a  vain  effort  to  restore  the  dog, 
respiration,  which  had  ceased  just  after  incision,  was  made.  The 
thoracic  and  abdominal  organs  were  examined  to  discover  if  any  lesion 
of  any  organ  would  account  for  death.  No  lesions  of  any  character 
were  discovered  in  any  organ.  Death  is  supj^osed  to  have  been  due  to 
injury  to  one  or  more  of  the  automatic  ganglia  from  the  penetration  by 
the  knife  in  making  incision. 

No.  18.  August  21,  1901,  2.40  p.  M. — A  black  mongrel  bitch,  age 
two  years,  weight,  35  pounds. 

Chest  opened  and  pericardium  divided  and  incision  made  in  the 
wall  of  the  left  ventricle.  This  incision  was  closed  by  two  sutures  of 
silk.  An  assistant,  in  making  the  first  puncture  with  the  needle  to  suture 
the  chest  wall,  made  too  deep  a  thrust,  and  injured  the  coronary  artery. 
Artificial  respiration  was  of  no  avail.  The  intention  was  to  complete 
the  operation  if  respiration  could  be  restored. 

Autopsy  made  at  2.50  p.  m.  proved  that  the  accident  was  a  benefit 
rather  than  a  loss,  as  it  permitted  several  valuable  observations  to  be 
made.  The  heart  continued  to  beat  four  minutes  after  removal  from 
the  thoracic  cavity.  It  was  discovered  that  the  suture  closing  incision 
in  the  heart's  wall  had  been  drawn  too  tight;  because  of  this,  and  be- 
cause of  the  high  tension  of  the  heart  muscles,  the  latter  had  been  torn. 
The  needle  which  was  the  cause  of  the  accident  was  a  very  large  one, 
with  cutting  edges.  The  holes  made  with  the  needle  in  the  heart  were 
fully  one-eighth  of  an  inch  long.  The  strain  upon  the  heart  muscle  was 
so  great  that  the  punctures  were  doubled  in  size.     The  autopsy  also 


Plate  XXXII. 


Experiment  on  the  Heart,  No.  i6,  page  269. 


i 


Experiment  on  the  Heart.  Xo.   18,  page  270. 
Showing  Silk  Sutures  ix  Place. 


RESEARCH  ON  THE  HEART  OF  THE  DOG       2^1 

showed  that  the  coronary  vein  had  been  punctured,  as  well  as  the  coro- 
nary artery.     (Plate  XXXII.) 

No.  19.  August  21,  1901,  3.15  p.  M. — Fox-terrier,  age  two  years, 
weight  15  pounds. 

Chest  cavity  opened  and  pericardium  divided.  At  this  stage  of  the 
operation  the  operator  accidentally  thrust  the  tenaculum  with  which 
he  was  attempting  to  pull  the  pericardium  up  from  the  heart,  in  order 
to  divide  it,  into  the  coronary  artery.  This  is  always  a  difficult  pro- 
cedure, because  the  pericardium  is  so  intimately  united  to  the  heart. 
A  silk  ligature  was  immediately  applied  to  control  the  haemorrhage. 
This  operation  was  performed  so  hurriedly  that  the  needle  used  in  ap- 
plying the  ligature  was  passed  through  the  pericardium,  which  was 
thus  enclosed  in  the  ligature.  Respiration  had  ceased  before  the  ligature 
could  be  appHed,  but  it  was  almost  immediately  restored  on  the  artery 
being  ligated.  Blood  spurted  out  with  great  force  when  the  walls  of 
the  artery  were  penetrated,  but  it  did  not  fill  the  pericardial  space.  It 
lost  its  fluidity  with  amazing  rapidity,  so  that  it  remained  quiescent, 
forcing  the  pericardium  out  like  a  balloon.  The  pericardium  began 
to  fill  and  stretch  as  long  as  the  haemorrhage  lasted.  Doubtless  the 
elastic  tension  of  the  pericardium  aided  also  in  preventing  the  blood 
from  flowing  into  the  pericardial  space.  All  this  combined  to  cause  a 
clot  to  form  very  quickly.  It  also  permitted  the  attachment  of  the 
fibrous  elements  of  the  blood,  thus  showing  how  fibrous,  exudative 
adhesions  are  formed. 

Autopsy.  Dog  died  August  25,  1901.  Post  mortem  held  8.30  a.  m., 
August  26th.  Infection  general.  Abdomen  distended  with  gas.  No 
fluid  in  the  thoracic  cavity.  Pericardium  and  pleura  adherent  to  each 
other,  and  both  adherent  to  the  heart  and  chest  wall.  A  bloody  infiltra- 
tion into  the  mediastinal  space,  and  also  into  the  cutaneous  structure, 
adjacent  to  the  thymus  gland.  The  adhesions  consisted  of  fibrous 
bands.  Both  pericardium  and  the  surface  of  the  heart  were  covered 
with  a  granular  exudate. 


PART    II 
THE    SURGERY    OF    THE    LUNGS 


Plate   XXXIII. 


First  tracheal  ring 
Impression  for  right  subclavian  arter)^ 
Upper  lobe 


rtery 


Lower  lobe 
Middle  lobe 


Left  lung 
Notch  for  the  heart 
Esophageal  impression 
Aortic  impression 

AXTKRFOR    \'lI£W    OF    THE    LuNCS, 


Lower  lobe 


(From  Deaver's  "Surgical  Anatomy.") 


PART    II 
THE   SURGERY   OF   THE    LUNGS 

INTRODUCTION 

No  part  or  organ  of  the  body  is  to-day  held  sacred  from 
the  surgeon's  knife. 

As  there  are  many  pulmonary  diseases  which  cannot  be 
cured  by  the  employment  of  the  agents  furnished  by  our 
modern  materia  medica,  attention  has  been  directed  to  the 
employment  of  surgical  means  to  cure  these  conditions. 

But  there  are  many  practical  difficulties  to  be  settled 
before  the  surgical  technique  for  pulmonary  operations  can 
be  estabHshed  on  a  firm  basis. 

In  order  to  devise  an  efficient  and  a  successful  tech- 
nique many  experiments  have  been  undertaken  by  dififerent 
workers. 

Wintrich,  as  early  as  1854,  made  a  series  of  experiments 
on  animals.  Pagenstecher  nearly  half  a  century  later  made 
another  extensive  series  of  similar  experiments.  The  latter 
demonstrated  that  animals  would  survive  both  resection  and 
excision  of  the  lung. 

Other  investigators  have  been  successful  in  similar  work. 
Still  many  little  details  remain  to  be  settled.  Many  investi- 
gators do  not  say  anything  about  their  methods,  and  it  is  just 
these  little  details  of  technique  that  are  needed. 

Some  writers  claim  that  experiments  on  animals,  no  mat- 
ter how  successful,  do  not  prove  that  man  can  safely  undergo 
the  same  operations. 

275 


276  THE  SURGERY  OF  THE  LUNGS 

At  the  congress  of  French  surgeons  in  Paris,  1895,  Reclus 
condemned  many  operations  for  pulmonary  diseases.  He 
says,  in  regard  to  tuberculous  diseases  and  primary  cancer 
of  the  lung,  that  resection  of  the  lung  for  these*  conditions  is 
"  condemned  past  appeal." 

In  criticizing  an  operator  for  cutting  ofT  the  protruded 
part  of  a  herniated  lung,  M.  Reclus  claimed  that  the  term 
resection  should  not  be  applied  to  such  procedures,  because 
none  of  the  healthy  lung  had  been  cut.  No  better  word  could 
be  used:  resection  comes  from  two  Latin  words,  the  insepara- 
ble particle,  re,  and  sectio,  given  by  Andrews  as  meaning,  a 
cutting  of  parts  of  the  diseased  body. 

Accepting  the  above  authority,  the  word  seems  sufficient 
to  characterize  the  operation  of  cutting  ofif  a  gangrenous  part 
of  a  lung. 

Reclus  is  one  of  those  who  believe  that  the  results  ob- 
tained by  experimentation  on  animals  cannot  be  applied  to 
man.  He  says :  "There  is  no  reason  in  resecting  the  human 
lung,  or  in  arguing  from  rabbits  to  men." 

M.  Reclus  is  referred  to  because  he  represents  a  certain 
class  of  writers  who  decry  all  bold  advances  in  the  applica- 
tion of  the  results  of  experimental  science. 

His  criticism  of  published  reports  has  some  truth  in  it. 
It  is  quite  true  that  sometimes  only  successful  cases  are  men- 
tioned, and  nothing  said  of  the  unsuccessful,  but  a  surgeon 
is  supposed  to  be  familiar  with  the  literature  of  his  profession. 
Long  before  1895  rnany  cases  were  published  of  operations 
on  the  lungs,  especially  for  those  conditions  in  which  Reclus 
condemns  surgical  interference. 

A  relatively  large  number  of  resections  for  hernia  of  the 
lung  have  been  tabulated.  One  table  shows  that  87^  per 
cent,  are  cured  when  operated  upon;  another  that  85  1-7  per 
cent,  are  cured. 

In  gangrene  60  per  cent,  recover  after  operation.  About 
71  per  cent,  recover  when  operated  upon  for  bronchiectasis; 


INTRODUCTION  277 

in  tuberculous  diseases  60  per  cent,  recover;  in  case  of  septic 
lesions  64.8  per  cent,  recover  when  pneumonotomy  is  em- 
ployed, and  in  case  of  aseptic  lesions  75.8  per  cent,  recover. 
In  a  late  list  of  306  cases  of  pneumonotomy  218  recovered 
and  88  died. 

These  figures  ought  to  be  conclusive  evidence  that 
surgical  interference  in  these  cases  is  justifiable.  Many  of 
the  diseases  enumerated  above  cannot  be  cured  by  other 
means,  and  any  method  of  treatment  that  will  cure  sixty  per 
cent,  of  what  otherwise  would  be  fatal  should  be  employed. 
It  is  no  excuse  for  a  surgeon  to  let  his  patient  die  because 
surgery  does  not  cure  all  cases,  or  because  some  prominent 
writer  proscribes  pulmonary  surgery.  If  arguments  from 
analogy  have  any  force,  the  strongest  possible  argument  for 
surgical  operations  for  tuberculous  diseases  of  the  lungs  can 
be  drawn  from  the  success  of  similar  work  in  case  of  tuber- 
culous abscesses  in  the  abdomen.  Patients  seemingly  almost 
moribund  are  relieved,  and  recover  from  the  operation  in  a 
surprisingly  short  time. 

Reclus's  statement,  "  I  know  of  no  instance  of  operation 
for  this  disease  in  the  lungs,"  speaking  of  actinomycosis,  may 
have  referred  only  to  France.  If  not,  it  shows  a  want  of 
knowledge  of  the  history  of  pulmonary  diseases. 

The  decade  preceding  1895  had  numerous  reports  of  cases 
of  actinomycosis  in  man.  The  German  surgeons  and  scien- 
tists wrote  extensively  on  this  subject,  and  there  are  a  large 
number  of  cases  of  this  disease  invading  the  human  lung. 
EngHsh  and  American  writers  also  published  cases. 

In  considering  the  feasibility  of  pulmonary  surgery  the 
fact  should  be  borne  in  mind  that  there  are  no  diseases  of 
any  part  of  the  body,  or  any  organ,  which  are  always  at- 
tended by  immediate  fatality,  and  there  are  but  few  injuries 
of  any  one  of  the  tissues  or  organs  of  the  body  which  are 
necessarily  fatal,  if  not  immediately  so. 

Hope  is  not  to  be  abandoned  under  any  circumstances, 


278  THE  SURGERY  OF  THE  LUNGS 

the  old  proverb  to  the  effect  that,  "  where  there  is  Hfe,  there 
is  hope,"  holding  good,  especially  in  diseases  of  the  lungs. 

The  diseases  which  are  held  to  be  incurable  are  not 
always  so,  because  many  instances  have  been  recorded  where 
they  have  yielded  to  some  kind  of  treatment,  or  have  been 
cured  spontaneously.  These  facts  are  to  be  kept  in  mind 
when  an  apparently  incurable  case  is  encountered. 


Plate  XXXIV. 


Anterior  View  showing  Apex  of  Heart  and  Tissues. 


Posterior  Mew. 
Normal  Human   Lung 


(Anatomy  of  the  Lung.) 


TERMINOLOGY 

Pneumatelectasis imperfect  expansion  of  the  lungs 

Pneumochysis pulmonary  oedema 

Pneumohaemia,     or     Pneumo- 

naemia congestion  of  the  lungs 

Pneumokoniosis;       pneumoco- 
niosis   lung  disease  caused  by  inhalation 

of  dust;  anthracosis,  when  caused  by  coal-dust,  coal-miner's 
lung ;  siderosis,  when  caused  by  metallic  dust ;  chalicosis,  when 
caused  by  mineral  dust 

Pneumonalgia pain  in  the  lungs 

Pneumonapoplexia a  sudden  hcemorrhage  into  the  lung 

tissue 
Pneumonectasia,    or    Pneumo- 

nectasis emphysema  of  the  lungs 

Pneumonemphraxis obstruction  of  the  lungs  or  bronchi 

Pneumonemphysema emphysema  of  the  lung 

Pneumonicula a  slight  inflammation  of  the  lung 

Pneumonoblennozaemia pulmonary  blennorrhcea 

Pneumonodynia pain  referred  to  the  lung 

Pneumonopathia any  disease  of  the  lung 

Pneumonoedema pulmonary  oedema 

PneumonorrhcEa haemorrhage  from  the  lungs 

Pneumonosyrinx a  fistula  of  the  lung 

Pneumonyperpathia any  very  grave  disease  of  the  lung 

Pneumoparesis progressive  congestion  of  the  lungs. 

due  to  faulty  innervation 

Pneumophthisis a  destructive  process  in  the  lung 

Pneumophyma a  tubercle  of  the  lung 

279 


280  THE  SURGERY  OF  THE  LUNGS 

Pneumophymia tuberculosis  of  the  lungs 

Pneumonitis pneumonia 

Pneumonocholosis bilious  pneumonia,   or  pneumonia 

accompanied  with  icterus 

Pneumonophlebitis inflammation    of    the    pulmonary 

veins 

Pneumonoscirrhus induration  of  the  lungs  associated 

with  bronchiectasis 
Pneumatosis air  in  abnormal  places,  or  in  exces- 
sive quantities 
Pneumocelcj  Pneumatocele, 

Pleuroccle hernia  of  the  lung 

(Pleurocele  is  sometimes  used  to  denote  a  serous  effusion  into 
the  pleural  cavity.) 

Pneumoclasia rupture  of  the  lung 

Pneumocace gangrene  of  the  lung 

Pneumatodyspnoea emphysematous  dyspnoea 

Pneumolith A  stony  concretion  in  the  lung — 

sometimes   used    to   denote    a 
calcified  tubercle 

Pneumomalacia abnormal  softness  of  the  lung 

Pncumosis,  or  Pneumonosis  . .  any  affection  of  the  lung 

Pneumonoscpsis septic  inflammation  of  the  lung 

Pneumorrhagia expectoration    of    blood    from    the 

lungs 

Pneumor desire  for  air,  or  to  breathe 

Pneumonocarcinoma carcinoma  of  the  lung 

Pneumoactinomycosis actinomycosis  of  the  lung 

Pneumocentesis paracentesis  of  the  lung 

Pneumonectomy  or  Pneumec- 

tomy excision  of  a  portion  of  lung 

Pncumonotomy  or  Pneumoto- 

my surgical  incision  of  the  lung 

Pulmonarious affected  with  pulmonary  disease 

Pulmoniferous provided  with  lungs 


TERMINOLOGY  28l 

Pleurapophysis a  true  rib 

Pleurapostema a  collection  of  pus  in  the  cavity  of 

the  pleura 

Pleurarthron the  articulation  of  a  rib 

Pleurarthrocace disease  of  the  costo- vertebral  joints; 

also  caries  of  the  ribs 

Pleuritis  or  Pleurisy inflammation  of  the  pleura 

Pleuroclysis  or  Pleuroklysis  ...injection  of  fluids  into  the  pleural 

cavity 

Pleurocollesis adhesion  of  the  pleural  layers 

Pleurogenic  or  Pleurogenous  .  originating  in  the  pleura 

Pleuron a  rib 

Pleuropathia  or  Pleuropathy  . .  any  disease  of  the  pleura 

Pleuropyesis purulent  pleurisy 

Pleurorrhagia haemorrhage  from  the  pleura 

Pleurorrhoea effusion  of  fluid  into  the  pleura 

Pleurostosis calcification  of  the  pleura 

Pleurotomy incision  of  the  pleura 

Bronchotomy a  surgical  cutting  operation  upon 

the  bronchus,  larynx,  or  trachea 
Bronchoplasty the  surgical  closure  of  a  tracheal 

fissure  or  fistula 
Bronchophyma any  growth,  as   a   tubercle,    in    a 

bronchial  tube. 


CHAPTER    I 
ANATOMY    OF   THE    LUNG 

The  lungs  are  thin  membraneous  sacs,  attached  to  the 
trachea.  There  are  two  sacs,  known  as  the  right  and  left 
lungs,  made  up  of  the  ramifications  of  the  bronchi,  blood- 
vessels, nerves,  and  lymphatics,  held  together  by  areolar 
tissue. 

The  external  framework  of  the  lungs  consists  of  the  pleura 
and  the  trabeculse  sent  down  between  the  lobes  and  lobules. 
The  right  lung  is  shorter  and  broader  than  the  left,  and  has 
three  lobes,  divided  by  two  fissures;  the  left  has  but  two 
lobes  and  one  fissure. 

The  pleura  is  formed  of  two  layers,  the  external,  a  fibrous 
membrane,  covered  by  large,  flat,  transparent,  endothelial 
cells,  and  the  subserous,  or  second  layer,  formed  of  loose 
areolar  tissue,  containing  many  elastic  fibres,  and  in  the  lower 
animals  non-striated  muscular  fibres. 

The  pleura  has  a  lymph  system  which  communicates  with 
that  of  the  sub-pleural  alveoli  on  one  side,  and  by  stomata 
with  the  pleural  cavity  on  the  other. 

The  bronchi  (properly  bronchia— BpSyxo^,  the  old  Greek 
word  from  which  the  modern  term  is  derived)  have  their 
origin  at  the  tracheal  bifurcation  opposite  the  third  dorsal 
vertebra,  and  terminate  in  the  pulmonary  lobules,  which  are 
miniature  lungs  themselves.  The  primary  tracheal  branches 
are  called  the  right  and  left  bronchus.  The  right  bronchus  is 
shorter,  larger,  and  more  horizontal  than  the  left,  and  enters 
the  lung  opposite  the  fifth  intercostal  vertebra,  while  the  left 
bronchus  enters  the  lung  opposite  the  sixth  dorsal  vertebra,  or 

282 


Plate  XXXV. 


X  IGO. 

Section    of   Injected   Human   Lung,    (Showing-  Air 

Cells). 


X  IGO. 

Section  Normal  Human  Lung. 


<Anatomy  of  the  Lung.) 


ANATOMY   OF   THE    LUNG  283 

two  inches  below  the  right.  (Charles  Carey,  "  Anatomy  of 
the  Bronchus.")  In  sheep  the  left  bronchus  grows  from  the 
trachea  direct. 

The  sccptiim  bronchiale,  which  separates  the  right  and  left 
bronchi,  is  placed  to  the  left  of  the  longitudinal  axis  of  the 
trachea;  this  is,  perhaps,  why  foreign  bodies  lodge  more  fre- 
quently in  the  right  bronchus. 

"  Monkeys  have  an  accessory  lobe  called  the  azygos  lobe. 
This  is  supplied  by  an  accessory  bronchus  which  arises  from 
the  right  bronchial  trunk  near  the  point  where  the  first  branch 
is  given  off."     (W.  S.  Miller.) 

Hyrtl  says  that  post  mortems  on  babies  dying  after  a  few 
respirations  show  that  the  right  lung  respires  before  the  left; 
he  claims  that  this  is  due  to  the  difference  in  size  and  loca- 
tion of  the  point  of  origin  of  the  right  bronchus. 

The  right  bronchus  sometimes  divides  into  three  branches; 
small  branches  are  also  sent  at  times  from  the  main  trunk. 
When  the  bronchi,  in  their  ramifications,  dwindle  to  about  yto 
of  an  inch,  they  enter  the  apices  of  the  pulmonary  lobules; 
branching  again  at  acute  angles,  they  dilate  sHghtly,  forming 
the  infundihiila  vesica. 

The  bronchi  are  hollow  cylindrical  tubes,  and  through- 
out the  greater  part  of  their  extent  exhibit  the  characteristics 
of  the  trachea.  They  are  formed  of  four  layers,  an  external 
fibrous,  a  muscular,  an  internal  elastic,  and  a  mucou3  layer. 
The  external  layer  consists  of  a  dense  network  of  connective 
tissue,  in  which  are  rings  of  hyaline  cartilage.  These  are 
disposed  in  broken  rings  in  the  primary  bronchi,  held  together 
by  fibrous  bands;  the  rings  are  completed  by  bundles  of  un- 
striped  muscular  fibres  attached  by  microscopic  tendons  to 
the  ends  of  the  rings,  which  by  their  contraction  increase 
the  curvature  of  the  cartilages  and  thus  diminish  the  calibre 
of  the  tube.  The  right  bronchus  contains  a  less  number  of 
these  cartilages  than  the  left;  as  the  distance  increases  from 
the  trachea  the  cartilages  gradually  lose  their  ring-like  shape, 


284  THE  SURGERY  OF  THE  LUNGS 

becoming  smaller  and  less  frequent,  until  they  finally  disap- 
pear, but  the  fibrous  layer  still  continues  to  form  the  external 
coat. 

Within  the  fibrous  coat  just  described  is  the  muscular 
coat.  It  consists  of  separate  bundles  of  unstriped  muscular 
fibres  disposed  transversely  to  the  tube.  It  is  better  de- 
veloped in  the  intervals  between  the  cartilages  than  just 
beneath  them.  The  muscular  coat  becomes  better  and  better 
developed  as  the  cartilages  disappear.  This  muscular  coat 
continues  to  the  final  branching  of  the  bronchioles  to  form 
the  alveolar  passages.  Here  it  develops  into  a  sort  of  sphincter 
at  the  point  of  entrance  to  the  alveolar  passages.  The 
function  of  this  layer  is  to  narrow  the  calibre  of  the  tube. 
The  contraction  of  the  bronchioles  is,  perhaps,  for  the  purpose 
of  expelling  collections  of  mucus  that  the  ordinary  ciliary  and 
expiratory  efforts  cannot  dislodge. 

Under  the  muscular  layer  and  the  mucous  membrane  are 
found  bundles  of  elastic  tissue.  It  is  this  layer  which  pro- 
duces the  wavy,  corrugated  appearance  on  transverse  section. 
Extending  through  this  layer  and  also  through  the  muscular 
layer  in  the  bronchial  tubes  containing  cartilages  are  the 
muciparous  ducts.  The  mucous  crypts  are  found  in  the  ex- 
ternal fibrous  layer,  principally  in  the  intervals  between  the 
cartilages.  The  mucous  layer  loses  its  character  in  the  ulti- 
mate tubules  and  comes  to  resemble  the  lining  membrane 
of  the  alveoli. 

The  bronchial  arteries  have  their  origin  in  the  thoracic 
aorta.  These  arteries,  after  having  received  branches  from 
the  first  intercostal  and  internal  mammary  arteries,  closely 
accompany  the  subdivisions  of  the  bronchi.  They  supply  the 
walls  of  the  bronchi,  the  pulmonary  vessels,  the  lymphatic 
glands,  and  the  connective  tissue  of  the  lungs.  They  termi- 
nate with  the  respiratory  plexus.  The  corresponding  veins 
empty  into  the  vena  azygos  and  the  vena  pulmonalis.  The 
venous  radicles  from  the  ultimate  bronchioles  empty  into  the 


ANATOMY   OF   THE   LUNG  285 

vena  pulmonalis  and  the  arterial  branches  into  the  vena  azygos. 
Hence  in  all  operations  involving  the  bronchus,  the  latter 
should  be  ligated  transversely,  whether  it  be  transverse  to 
the  lung  or  not. 

The  lymphatics  rise  from  the  alveolar  sseptum.  They 
communicate  directly  with  the  alveolar  cavity  by  stomata 
in  the  alveolar  walls.  The  lymphatics  form  a  plexus  in  the 
submucous  tissue  accompanying  the  branches  of  the  bronchi, 
as  well  as  the  pulmonary  veins  and  arteries,  emptying  finally 
into  the  bronchial  glands  at  the  roots  of  the  lungs.  They 
often  present  a  gray  or  black  speckled  appearance  from  the 
absorption  of  pigment  or  foreign  bodies. 

The  pulmonary  plexuses  are  formed  from  branches  of  the 
vagus  and  symphatheticus.  The  filaments  of  these  plexuses 
follow  the  ramifications  of  the  bronchi,  and  finally  become 
lost  on  them  in  the  parenchyma  of  the  lungs. 

The  sensibility  of  the  bronchi  is  thought  to  be  sHght, 
especially  in  the  smaller  branches,  because  consumptives 
make  little,  complaint.  But  the  destruction  wrought  in  tuber- 
culosis is  so  thorough  that  the  nerves  are  included  in  the 
fell  process. 

It  now  remains  to  describe  the  alveoli.  These  are  irregu- 
lar dilatations  into  which  the  alveolar  passages  terminate.  They 
even  remain  partly  dilated  after  death,  until  the  thoracic 
cavity  is  opened  and  they  are  subjected  to  the  pressure  of 
the  atmosphere.  Their  walls  are  the  continuation  of  the 
infundibula  and  consist  of  very  thin  connective  tissue,  within 
which  greater  or  smaller  bundles  of  elastic  fibres  are  scat- 
tered. They  also  contain  the  black  masses  known  as  lung 
pigment.  This  pigment  is  not  melanin,  but  foreign  particles 
from  the  atmosphere  which  make  their  entrance  into  the 
alevoli  during  respiration.  In  wild  animals  in  their  native 
state  this  pigment  is  never  found;  it  is  only  present  after 
they  have  been  brought  to  the  dusty  and  smoky  habitation 
of  man. 


286  THE  SURGERY  OF  THE  LUNGS 

The  lung  receives  its  blood  supply  from  two  systems,  the 
bronchial  and  the  pulmonary.  The  former  has  been  already 
described. 

The  larger  pulmonary  arteries  and  veins  are  situated  in 
the  intralobular  connective  tissue.  They  subdivide  into 
minute  vessels,  each  encircling  an  alveolus,  and  then  split 
up  into  a  very  fine  capillary  network,  only  separated  from 
the  air  by  the  exceedingly  thin  alveolar  membrane.  Only 
a  single  mesh  of  capillaries  exist  in  an  inter-alveolar  sseptum. 

Malpighi  (1661)  was  the  first  to  discover  in  the  lungs  and 
mesentery  of  frogs  the  capillary  circulation  and  lung-cells. 
In  ReptiHa,  only  one  surface  of  the  capillaries  is  exposed 
to  the  air,  while  in  man  the  arrangement  is  such  that  all 
sides  of  the  capillaries  are  so  exposed. 

The  pulmonary  veins  have  their  origin  in  the  inter- 
alveolar  saeptum,  uniting  gradually  to  form  larger  and  larger 
branches.  They  accompany  the  bifurcations  of  the  bronchi 
to  the  hilus  of  the  lungs.  There  is  one  peculiarity,  that  the 
vascular  area  of  the  pulmonary  veins  is  narrower  than  that 
of  the  corresponding  arterial,  being  an  exception  to  the  rule. 

The  lung  is  richly  supplied  with  lymphatics,  there  being 
three  systems,  all  of  which  intercommunicate  freely.  The 
first  system,  peribronchial,  has  already  been  described.  The 
other  two  begin  in  the  lymphatic  canalicular  system,  connect- 
ing the  various  alveoli.  The  subpleural  take  their  origin 
from  those  in  the  subpleural  alveoli,  and  with  branches  from 
the  pleural  system,  terminate  partly  in  the  bronchial  glands 
at  the  hilus,  and  partly  unite  with  the  perivascular  lymphatics 
in  the  interlobular  connective  s?eptum.  The  perivascular  sys- 
tem has  the  same  origin  as  the  subpleural,  and  following  the 
arteria  pulmonalis,  terminate  in  the  bronchial  glands.  All 
three  systems  have  valves  situated  in  slight  saccular  dila- 
tations. 

The  nerves  of  the  lungs  have  their  origin  in  the  pulmonary 
plexuses,  which  are  formed  of  branches  of  the  pneumogastric 


Plate  XXXVI. 


mmf 


^•^ 


^^ 


■H  ^-   ii^ 


X  GO. 


X  40. 


Sections  of  Normal  Lung  of  a  Water  Dog, 
(Necturus  Lateralis). 


(Anatomy  of  the  Lung.) 


ANATOMY   OF   THE   LUNG  287 

and  sympathetic.  They  enter  the  lung  with  and  follow  the 
divisions  of  the  bronchi.  Both  medullated  and  non-medullated 
nerve  fibres  containing  numerous  small  ganglia  exist  in  bun- 
dles. They  are  distributed  to  the  blood-vessels  and  walls 
of  the  branches. 

Pathologic  changes  in  the  lungs  tend  to  produce  cica- 
trices. When  any  of  the  bronchioles  are  cut  off  by  disease 
or  cicatrices,  that  portion  of  the  lung  beyond  the  cicatrix, 
which  is  directly  connected  with  the  severed  bronchus,  be- 
comes useless.  This  is  true  even  if  the  lung  tissue  be  itself 
in  a  healthy  condition.  Therefore,  there  is  a  loss  of  capacity 
after  every  accident  or  disease  that  causes  loss  of  lung  tissue. 

In  1894  Meckel  published  his  report  on  the  apparatus 
of  respiration,  and  in  1895  appeared  Boruttan's  report  of  the 
examination  of  the  lung  nerves.  This,  apparently,  is  one  of 
the  neglected  fields  of  human  knowledge  and  scientific  inves- 
tigation. 

Notes — The  lung  of  the  "  mud-puppy  "  or  "  water-dog  " 
(Necturus  lateralis),  consists  of  two  elongated,  cylindrical 
bodies.  Both  the  outer  and  inner  surfaces  are  smooth.  There 
is  both  an  arterial  and  venous  system.  These  are  so  ar- 
ranged that  each  vein  is  at  right  angles  to  the  corresponding 
artery. 

The  lung  in  snakes  (they  have  only  one)  is  an  elongated, 
cylindrical  body.  It  is  smooth  two-thirds  of  its  length.  The 
posterior  third  is  divided  into  numerous  air-cells  which  com- 
municate with  a  central  cavity.  There  seems  to  be  no  com- 
munication between  the  air-cells. 

In  birds  the  lungs  are  attached  closely  to  the  ribs.  The 
bronchus  after  penetrating  into  the  lungs,  breaks  up  into 
numerous  tubular  passages.  These  passages  are  not  true 
bronchia,  since  the  alveoli,  or  true  lung  structure,  arise  di- 
rectly from  them.  The  principal  bronchi  communicate  by 
large  rounded  openings  with  large  air-bags  situated  in  the 
abdomen  and  in  the  hollow  bones.     These  air-bags  should 


288  THE  SURGERY  OF  THE  LUNGS 

be  considered  as  part  of  the  lungs,  as  they  are  directly  con- 
nected with  the  bronchi.  The  air-sacs  do  not  communicate 
with  one  another. 


BIBLIOGRAPHY 

Carpenter^    Wm.,    Comparative    Physiology.    Philadelphia, 

1854- 
Jones  and  Sieveking,  Pathological  Anatomy.     Philadelphia, 

1854- 
Meckel,    Respiration    Apparatus.      Anat.    Heft.,    Wiesburg, 

1894. 
Boruttan,  Examination  of  the  lung  nerves.    Arch.  f.  d.  Ges. 

Phy.,  Bonn,  1895,  LXI,  39-76. 
Gray,  Anatomy. 
Devic  et  Paviot,   Lyon  Med.,    1901,  XCVI,   45-56;  figs., 

91-102. 


CHAPTER  II 
ABNORMALITIES 

That  congenital  abnormalities  of  the  lungs  should  be 
properly  considered  from  a  surgical  point  of  view,  it  is  neces- 
sary that  all  such  defects  of  the  thoracic  viscera  should  be 
reviewed.  As  a  rule,  a  congenital  defect  of  one  destroys  the 
landmarks  of  all  of  the  thoracic  viscera.  The  diaphragm 
may  have  its  attachments  higher  or  lower  than  commonly 
described,  while  the  mediastinal  space  may  be  entirely  obHter- 
ated,  congenitally,  or  by  subsequent  irritation.  The  peri- 
cardium, while  never  having  been  found  absent,  may  be  very 
much  thickened,  adherent,  and  malpositioned. 

The  pulmonary  vessels,  both  arterial  and  venous,  are  per- 
haps more  frequently  malformed  than  is  generally  supposed, 
while  the  bronchus  in  one  or  both  lungs  has  been  found 
absent.  The  absence  of  one  need  not  result  in  death.  The 
bronchi  are  also  prone  to  malposition,  indeed,  they  are  sub- 
ject to  as  great  a  variety  of  anomalies  as  the  blood-vessels 
themselves. 

The  bony  chest  may  vary  from  the  normal  formation, 
and  thereby  displace  one  or  all  of  the  thoracic  viscera. 

Any  one  or  all  of  these  abnormalities  may  be  congenital, 
or  acquired  by  injury,  or  the  formation  of  new  tissue,  such 
as  the  benign  or  malignant  growths,  cysts,  fluid,  or  foreign 
bodies  of  any  character  within  or  without  the  chest  cavity. 
Malposition  of  the  thoracic  viscera  is  especially  to  be  found 
in  caries  of  the  dor:^  1  vertebrae.  It  is,  therefore,  important 
that  these  conditions  should  be  thoroughly  considered  be- 

2S9 


290  THE  SURGERY  OF  THE  LUNGS 

fore  attempting  any  operative  measures  upon  the  lung,  for 
the  adoption  of  such  measures  is  far  more  important  in 
abnormalities  than  in  normalities. 

Historical  (1783-1903). — Tichomirofif  reported  a  case  of 
congenital  absence  of  the  left  lung,  which  was  found  in  a 
woman  twenty-four  years  old,  who  died  of  pneumonia.  He 
also  mentions  four  cases  of  absence  of  left  lung  in  men.  There 
can  be  no  reason  assigned  why  the  left  lung  should  be  oftener 
absent  than  the  right.  Necropsy  in  the  case  of  the  woman 
revealed  no  difference  in  the  vagi  of  the  two  sides.  A  left 
superior  vena  cava  was  present,  while  the  left  thymus  was 
larger  than  the  right. 

(The  left  lung  in  snakes  is  rudimentary.  See  notes  at 
end  of  chapter  on  anatomy.) 

One  or  both  lungs  may  be  absent  in  man  or  animals,  or 
they  may  be  partially  developed,  or  converted  into  numerous 
sacs  containing  air  and  serum,  and  connected  with  one  or 
more  bronchi.  (Delafield  and  Prudden,  "  Path.,  Anat.  and 
Hist,"  1892,  p.  354.) 

Kirsch  (1889)  reported  an  interesting  case  of  irregular 
formation  of  the  lung,  while  Wollman  (1891)  mentioned  a 
similar  condition.  Schmidt  (1893)  described  a  pathological 
lung,  while  Hoffman  (1783)  reported  a  case  of  diaphragmatic 
junction  with  the  lungs.  Boca  (1852)  reported  the  complete 
separation  of  the  two  lobes  of  the  lung.  Thomson  (1886) 
collected  cases  of  thoracic  defects,  and  states  that  there  may 
be  rupture  of  lung,  not  hereditary,  but  probably  due  to  the 
pressure  of  the  arm  against  the  chest. 

Pavy  gives  a  very  remarkable  case  of  sternal  fissure  in 
a  young  German  twenty-five  years  old.  There  was  a  longi- 
tudinal groove  outlined  with  a  hard  ridge,  which  articulated 
with  the  costal  cartilages  instead  of  a  sternum.  Alderson 
gave  a  report  of  a  case  of  diaphragmatic  hernia  with  symp- 
toms of  pneumothorax,  which  ended  fatally.  Gibson  and 
Malet  reported  a  case  of  praesternal  fissure  uncovering  the 


Plate  XXXVIL 


X  4U. 


^ 


^^S 

'^5^ 


X  40. 

Sections  of  Normal  Lung  of  a  Black  Snake. 


(Anatomy  of  the  Lung.) 


ABNORMALITIES  29I 

base  of  the  heart.  Chene  (1870)  gives  an  account  of  a  super- 
numerary lobe  to  the  right  lung. 

Dicky  (1870)  published  an  account  of  malformation  of 
the  lung.  Tyson  (1872)  reported  a  case  of  congenital  deficient 
left  lung.  Collins,  in  1874,  published  a  case  of  accessory  pul- 
monary lobe  of  the  vena  azygos,  and  Hodges  published  a  case 
in  which  there  was  exstrophy  of  the  heart  through  the  fissure. 

Testut  and  Marcendes  gave  a  description  of  a  lung  with 
six  lobes.  Humphrey  (1884)  reported  a  case  of  an  accessory 
lobe  to  the  left  lung.  Thermin  (1884)  reported  cases  of  the 
congenital  absence  of  the  left  lung.  Madden  reported  the 
case  of  a  Swede,  forty  years  old,  with  congenital  absence  of 
middle  of  the  sternum,  leaving  a  fissure  5f  inches  long.  Ed- 
wards (1885)  reported  an  anomalous  lung  (human)  having 
four  lobes  on  the  right  side,  and  much  valuable  material  was 
given  in  Maylard's  (1885)  article  on  the  abnormalities  of 
the  human  lung. 

Lukin  (1885)  reported  two  cases  of  entire  absence  of  the 
lung.  Lamb  (1886)  published  an  account  of  anomalous  loba- 
tion  of  the  human  lung.  Kirsch  (1889)  published  a  report  of 
congenital  pulmonalostien-stenose.  Wollmans  and  Schmidt 
also  give  interesting  reports.  Rheinhold  (1893)  and  Bowles 
(1893),  report  the  finding  of  four  lobes  on  the  right  side. 
Motti  (1893)  pubHshed  a  case  of  rare  anomaly  of  the  lung. 
Tichomirofif,  Durck,  and  Eckley  (1895)  mention  accessory, 
anomalous  or  abnormal  cases  of  lobation.  Bouchard  reported 
a  case  of  absence  of  the  right  half  of  the  diaphragm  in  a  new- 
born child,  while  Berchon  reported  a  double  perforation  of 
the  diaphragm  with  hernia  of  the  epiploon. 

Lawrence  (1896)  reported  a  case  of  abnormal  lobe.  Dum- 
erin,  of  Lyons,  showed  an  infant  of  eight  days  which  had 
arrested  development  of  the  second,  third,  fourth,  and  fifth 
ribs.  Carper  found  a  foetus  of  thirty-seven  weeks  in  which 
there  were  no  lungs,  only  a  voluminous  thymus  gland. 

Wister  (1897)  gave  an  account  of  a  person  in  whom  one 


292  THE  SURGERY  OF  THE  LUNGS 

side  of  the  thorax  was  at  rest,  while  the  other  performed  the 
movements  of  breathing  in  the  usual  manner.  Diemerbroeck 
is  reported  to  have  dissected  a  human  subject  in  whom  the 
diaphragm  and  mediastinum  were  apparently  missing.  Schafer 
(1898),  Matthews  (1898),  and  Springer  (1898),  each  men- 
tion the  same  anomalous  lobation  of  the  human  lung. 

Herxheimer,  Central  f.  dimere  Medical,  Leipsic,  July  i, 
1 901,  mentions  an  autopsy  of  a  three-weeks'-old  infant  in 
which  bifurcation  of  the  trachea  was  noted,  and  a  third  lung 
was  discovered  communicating  with  it  by  a  separate  bronchus. 
All  three  lungs  had  fatal  catarrhal  pneumonia. 

Three  cases  of  rudimentary  lungs  have  been  recorded, 
but  this  was  the  first  in  which  they  had  actual  functional 
connection  with  the  trachea. 

These  reports  of  anomalies  illustrate  the  fact  that  devia- 
tion from  the  normal  in  structure  is  not  necessarily  inimical 
to  life,  and  also  prove  that  deviation  from  the  type  is  as 
frequent  in  the  genus  Homo  as  in  genera  of  the  lower  orders. 
In  fact,  the  higher  the  order  and  genus,  the  greater  the  fre- 
quency of  anomalies,  and  the  greater  the  deviation  struct- 
urally from  the  type. 


BIBLIOGRAPHY 

Hoffman,  A   System  of  Prac.  of  Med.,  Trans,   by  Lewis. 

London,  1783. 
Broca,  Bull.  Socictc  d'anatomie,  Paris,  XXVII,  29,  1852. 
Thomson,    Teratologia,    London    and    Edinburgh,    January, 

1855. 
Pavy,  Medical  Times  and  Gazette,  London,  1857,  II,  522. 

Alderson,  Lancet,  London,  1858,  II,  396. 

Gibson  and  Malet,  Transactions  Coll.  of  PJiys.,  Philadelphia, 

i860,  III,  310. 
ViRCHOw's,  Arch.,  Bd.  XXXVIII,  S.,  173,  1867. 


ABNORMALITIES  293 

CiiENE,  Journal  Anat.  and  Phys.,  London,  1870,  IV,  89. 
Dicky,  Lancet  and  Observer,  1870,  XIII,  407. 
Tyson,  Philadelphia  Medical  Times,  1872-73,  Illb,  221. 
Collins,  Dublin  Journal  Medical  Science,  1874,  LVIII,  252. 
Hodges,  American  Practitioner,  Louisville,  October,  1878. 
Testut  and  Marcendes,  Gazette  Hebd.  de  Science  Medicate 

de  Bordeaux,  1880,  I,  1045. 
Humphrey,  Journal  Anat.  and  Phys.,  London,  1884-85,  XIX, 

345- 
Theremin,  Revue  de  Mai  de  I'Enfance,  Paris,  1884,  II>  554^ 

565- 
Edwards,  American  Journal  Medical  Science,  Philadelphia, 

1885,  n.s.  XC,  pp.  182-86. 
Maylard,  Journal  Anat.  and  Phys.,  London,  1885-86,  XX, 

34-38. 
LuKiN,  Med.  Prinban.  Knoraksbornikin,  St,  Petersburg,  1885. 

pp.  423-428. 
Lamb,  Medical  News,  Philadelphia,  1886,  XLVIII,  181. 
KiRSCH,  Bonn,  1889,  33. 
WoLLMANS,  Dresden,  1891,  p.  36. 
Reinhold,  Miinich.  Med.  IVoch.,  1893,  845-869. 
Bowles,  Proc.  Anat.  Society  Gr.  Britain  and  Ireland,  London, 

1893,  pp.  2-4. 
MoTTi,  Gior.  Internas.  d.  Soc.  Med.  Napoli,  n.s.,  XV,  881-892. 
TiCHOMiROFF,  Inter.  Anat.  und  Phys.,  1895,  Bd.  XII,  8-24. 
DuRCK,  Sitz.  d.  Gesellsch.  f.  Morph.  und  Prms.,  Muench.,  1895, 

X,  21. 
EcKLEY,  British  Medical  Journal,  London,  1895,  I,  416. 
Bouchard,  Bidl.  de  la  Socicte  d'Anat.,  Paris,  1896,  XXXVIII, 

344- 
Berchon   Gazette  dcs  Hopitaux  de  Paris,  1896,  XXXV,  447. 
Lawrence,  Proc.  Anat.  Society,  Great  Britain  and  Ireland, 

1896-97,  XXX. 
Dumerin,  Gould  and   Pyle's   Anomalies  et  caetera  of  Med. 

Philadelphia,  1897. 


294  "T^E   SURGERY   OF   THE    LUNGS 

Carper,  Gould  and  Pyle's  Anomalies  et  caetera.  Philadelphia, 
1897. 

WiSTAR,  Gould  and  Pyle's  Anomalies  et  caetera.  Philadelphia, 
1897. 

DiEMERBROECK^  Gould  and  Pyle's  Anomalies  et  caetera.  Phila- 
delphia, 1897. 

ScHAFFNER,  Avch.  Path.  Anat.,  1898,  GUI,  1-25. 

Matthews,  Proc.  Anat.  Society,  Great  Britain  and  Ireland, 
1898,  34-38. 

Springer,  Prag.  Med.  Woch.,  1898,  pp.  393-395- 

Carre,  Paris,  1900. 


CHAPTER  III 

EXPERIMENTAL     RESEARCH     (1795-1903)— INFLUENCE 
OF   TRAUMA   ON   THE    LUNGS   AND    HEART 

More  than  a  century  ago  attention  was  turned  to  the 
experimental  study  of  the  lungs.  Davidson's  observations 
on  the  anatomy  and  pathology  of  the  pulmonary  system  in 
1795  mark  the  first  recorded  step  in  this  direction.  Some 
little  time  elapsed  before  Harlan,  in  1819,  showed  by  experi- 
ments on  living  animals,  that  the  circulation  of  the  blood 
through  the  lungs  is  immediately  and  entirely  suppressed 
during  expiration.  Carson  gave  science  the  result  of  his  re- 
searches on  the  elasticity  of  the  lung  in  1820.  In  1832  ap- 
peared Caste's  historical  resume  of  the  principal  discoveries 
upon  the  structure  and  functions  of  the  lungs.  This  is  very 
valuable,  especially  to  those  interested  in  the  history  of  medi- 
cine, and  it  is  none  the  less  so  because  of  the  practical  ob- 
servations embodied  in  it. 

The  next  step  forward  was  by  Schiitzenburger,  who,  in 
1832,  published  his  studies  on  the  physiological  effects  of 
certain  dynamic  lesions  of  the  lungs.  Rossignol,  in  1848, 
gave  the  result  of  his  researches  on  the  respiratory  organs 
of  man  and  the  principal  mammals,  thus  completing  the 
work  of  T.  Addison  on  the  anatomy  of  the  lungs,  and  that 
of  W.  Addison  on  the  ultimate  distribution  of  the  air  passages, 
and  the  formation  of  the  air-cells  in  the  lungs. 

Certain  problems  were  solved  in  1847  by  Sappy  in  his 
great  work  on  the  respiratory  organs  of  birds.  Cauman,  in 
1848,  showed  that  the  capillaries  of  the  lungs  do  not  anasto- 

295 


296  THE  SURGERY  OF  THE  LUNGS 

mose.  Le  Fort,  in  1858,  devoted  himself  to  the  study  of 
the  anatomy  of  the  human  kmg.  Waters  investigated  the 
ultimate  structure  and  distribution  of  the  blood-vessels  of 
the  human  lung. 

Bert,  in  1869,  brings  us  back  to  pure  science  by  his  work 
on  the  elasticity  and  contractility  of  the  lungs,  and  the  con- 
nection of  these  properties  with  the  pneumogastric  nerves. 
Brown's  article  on  the  alveoli  of  the  lung  containing  squamous 
epithelium  is  a  most  concise  one,  and  offers  many  suggestions 
concerning  the  repair  of  the  lung  tissue.  D'Arsonval's  re- 
searches (1887),  theoretical  and  experimental,  upon  the  part 
played  by  the  elasticity  of  the  lungs  in  the  phenomenon  of 
circulation  should  be  consulted. 

Grehant  (1879)  brings  us  to  the  employment  of  physics  in 
physiological  investigation,  by  his  study  of  endosmosis  of 
gases  in  the  detached  lung.  Casse,  previously,  had  given 
the  results  of  his  experiments  on  the  absorption  and  elimina- 
tion of  gas  by  the  internal  organs  of  animals.  Heger  (1880) 
followed  with  his  researches  on  the  circulation  of  blood  in 
the  lungs.  Roy  and  Brown  (1885)  showed  that  the  bronchi 
contract  under  certain  conditions. 

Gage  (1885)  showed  the  value  and  necessity  of  histologi- 
cal investigations,  by  his  paper  embodying  the  result  of  his 
study  of  the  structure  of  the  respiratory  membrane  in  the 
pharynx  of  the  soft-shelled  turtles.  The  important  work  of 
Lamb  (1886)  showed  that  anomalous  lobation  of  the  lung 
is  not  infrequent,  while  the  normal  position  of  the  lungs  is 
a  little  more  than  an  inch  above  the  first  rib.  Cruveilhier  was 
the  first  to  show  by  the  dissection  of  a  foetus  that  one  or  both 
apices  may  extend  along  the  cervical  spine. 

Here  it  may  be  remarked,  that  the  fact  that  the  peri- 
cardium has  never  been  found  absent,  should  be  remembered 
in  eliminating  its  absence  in  herniated  lung  of  the  left  side; 
it  should  also  not  be  forgotten  that  the  lower  costal  cartilages 
on  the  left  side  in  women  are  rare.    The  cervical  ribs  are  also 


Plate  XXXVIII. 


X  40. 


X 


X  40. 


Sections  Normal  Lung  of  a  Bird,  (Martin). 


(Anatomy  of  the  Lung.) 


EXPERIMENTAL   RESEARCH    (l795 — I9O3)  297 

rare,  as  shown  by  post  mortems;  there  are  but  two  cases 
reported  clinically. 

It  is  only  in  comparatively  recent  times  that  experiments 
have  been  made  on  the  excision  of  the  lung.  Richard  (1880) 
reported  a  penetrating  wound  of  the  thorax  with  immediate 
pneumocele.  Excision  of  the  lung  was  employed  in  this  case, 
and  the  patient  recovered.  Schmidt  (1881)  gave  the  result 
of  his  experimental  studies  on  partial  lung  resection;  Block 
(1881)  also  made  similar  researches. 

In  1881  appeared  Marcus's  researches  upon  the  experi- 
mental extirpation  of  the  lung.  Biondi  followed  with  his 
reports  on  the  same  subject,  and  in  1884  published  the  results 
of  the  extirpation  of  the  lung,  following  the  experimental 
localization  of  a  tubercle. 

Rcchcrchcs  experiment  ales  et  critiques  stir  I'ahsorption  et 
I' exhalation  pulmonaires  are  none  the  less  interesting  because 
Pagenstecher  (1895),  by  his  work  upon  rabbits,  disproved 
those  of  Eintrich  (1854),  in  which  the  latter  found  that  blood 
introduced  into  the  pleura  would  become  absorbed  without 
pleuritic  adhesions  after  the  eighth  day. 

Mechanical  injuries  of  the  lung  due  to  manipulation,  con- 
tusion, stab  wounds,  gunshot  wounds,  et  csetera,  on  the  whole 
seem  to  affect  the  heart  more  than  the  respiratory  organs. 
There  is  great  difficulty  in  making  satisfactory  observations 
on  this  point.  Some  observations  showed  very  marked 
"  Vagel  "  heart  beats  on  pinching  the  lung  with  the  fingers. 
(Crile,  "Surgical  Shock,"  1899,  p.  129.) 

Mammals  have  a  diaphragm,  but  the  amphibia  and  lower 
orders  of  animals  do  not.  (Byron  Robinson,  "  Peritonaeum," 
1897,  p.  120.)  Pinching  the  lung  near  the  base  of  the  heart 
produces  irregular  heart  and  a  slight  decline  of  the  blood 
pressure.  (Crile,  "On  Shock,"  1899,  p.  80.)  The  rhythm  of 
the  lung  is  controlled  by  the  peripheral  ganglia,  or  the  auto- 
matic pulmonary  ganglion  which  is  situated  in  the  lung  sub- 
stance. 


298  THE  SURGERY  OF  THE  LUNGS 

Crile  ("Surgery  of  the  Respiratory  System,"  26.  edition, 
1900,  pp.  32-33),  reports  the  results  of  his  experiments  upon 
a  dog.  He  gave  a  blow  over  the  right  side  of  the  chest  dur- 
ing chloroform  narcosis.  He  found  that  the  respiratory  action 
became  irregular,  with  a  marked  fall  of  blood  pressure. 

Reinboth's  (1896-97)  experimental  study  in  lung  dilata- 
tion, Crile's  (1899)  summary  of  an  experimental  research  in 
the  surgery  of  the  respiratory  system,  and  Carraras's  (1898) 
mechanism  of  pulmonary  lesions,  are  the  only  publications 
which  have  appeared  in  the  last  few  years. 

Dr.  S.  P.  Kramer,  of  Cincinnati,  in  1900,  injected  agar- 
agar  into  the  pleural  cavity  to  fix  the  lungs.  The  success 
of  this  procedure  encouraged  him  to  inject  it  into  hernial 
sacs  to  prevent  recurrence  of  the  hernia.  There  has  not 
been  sufficient  time  since  to  determine  just  how  success- 
ful this  method  has  been.  But  enough  is  known  to  urge  him 
to  carry  on  his  experiments.  Dr.  Kramer  claims  that  not 
only  is  the  agar-agar  absorbed,  but  there  is  evidence  from 
microscopical  examination  that  reorganization  takes  place. 
The  cavity  fills  with  connective  tissue,  at  least  there  is  new 
cell  formation,  which  in  structure  resembles  connective  tis- 
sue. {Annals  of  Surgery,  August,  1901,  p.  273,  Vol.  XXXIV, 
No.  2.) 

BIBLIOGRAPHY 

Davidson,  London,  1795. 

Harlan,  Electrical  Reporter,  Philadelphia,  1819,  IX,  122-128. 
Carson,  J.,  Philadelphia  Trans.,  London,  1820,  CX,  29-44. 
Gaste,  An.  de  la  Med.  Phys.,  Paris,  1832,  XXI,  pp.  236-278. 
Addison,  T.,  Med.-Chir.   Trans.,  London,    1840-41,  XXIV, 

146-154. 
Addison,  W.,  Philadelphia  Trans.,  London,  1841-42,  XXXIV, 

157-161. 
Cauman,  New  York  Medical  Journal,  1848-76,  X,  27-32; 

Medical  Gazette,  New  York,  VI,  pp.  31-32. 


EXPERIMENTAL   RESEARCH   (l795  — 1903)  299 

Bert,  Coiiipt.  Rend.  Socicte  dc  Biologie,  1868  (Paris,  1889), 

V,  55-57- 
D'Arsonval^  Paris,  1877. 
Grehaut^  Compt.  Rend.  Societe  de  Biologie,   1877    (Paris, 

1879),  IV,  429-432. 
Casse^  Bull.  Acad,  de  Medicine  de  Belgique,  1878,  XII,  652- 

662. 
Garland,  Pneumono-Dynamics,  New  York,  1878. 
Leyden,  Charite-Annalen,  1878,  III. 

BowDiTCH,  Journal  Phys.,  London,  1879,  II,  91,  109,  1879.. 
HoMOLLE,  Revue  Mens.,  1879,  No.  2. 
LiCHTHEiM,  Arch.  f.  Experim.,  Path.,  1879. 
Richards,  Indian  Medical  Gazette,  Calcutta,  1880,  VI,  213. 
Schmidt,  Berlin.  Klin.  Woch.,  1881,  XVIII,  757-759. 
Block,  Dent.  Medical  Woch.,  Berlin,  188 1,  VII,  634-636. 
Marcus,  Compt.  Rend.  Societe  de  Biologie,  Paris,  1882,  III, 

323- 

D.  BiONDi,  Gior.  Internaz  d.  Soc.  Med.     Napolia,  1882,  n.s., 

IV,  759,  1883,  n.s.,  V,  248-417. 
Brown,  Lancet,  London,  1884,  II,  681. 
Gage,  Proc.  American  Association  Adv.  Sc,    1885,   Salem, 

1886,  XXXIV,  345-349- 
Lamb,  Medical  Nezvs,  Philadelphia,  XLVIII,  181 ;  Klin.  Vortr. 

15  and  16,  Vortr.,  Leipzig,  1889,  F.  C.  W.  Vogel ;  Klin. 

Vortr.  V.  Resp.  App.,  6,  F.  C.  W.  Vogel,  gr.  8,  pp.  18; 

Gior.  Internaz.   d.   Soc.   Med.,   Napoli,    1894,   n.s.,    Ill, 

736-41. 
Reinboth,  Deut.  Arch.  Klin.  Medical,  1896-97,  LVI,   178- 

209. 
Carrara,  Gior.  di  Medical  leg.,  Lanciano,  1897,  V,  161-173. 
Crile,  Cleveland  Medical  Journal,  1899,  IV,  57-81. 
Quincke,  Deutsches  Arch.  f.  Klin.  Medical,  XXI 
RosENBACH,  O.,  Virchow's  Arch.,  B.  CV,  No.  2. 
Schreiber,  J.,  Deutsches  Arch.   f.  Klin.  Medical,  XXXIII. 
VON  ZiEMssEN,  Klin.  Vortr.  v.  Resp.  App.,  5,  Leipzig,  F.  C.  W. 

Vogel,  gr.  8,  p.  16. 


CHAPTER    IV 
HISTORY   OF   LIGATURES  AND   SUTURES 

SusRUSTAS  ( 1 500  B.  c. )  WES  the  first  to  apply  a  ligature. 
He  tied  the  umbilical  cord  of  new-born  babies  before  severing 
it.  A  passage  in  the  writings  of  Hippocrates  has  been  in- 
terpreted to  mean  that  the  Father  of  Medicine  was  familiar 
with  the  use  of  the  ligature.  Archigenes  (100  b.  c.)  was  the 
first  to  use  ligatures  in  amputations. 

Celsus  (30-25  B.  c.^  A.  D.  45-50)  speaks  of  the  ligature  as 
something  well  known;  he  used  ordinary  linen  thread.  Galen 
(a.  d.  13 1-2 1 1 )  advised  ligatures  to  be  applied  at  the  proximal 
end  of  injured  vessels;  he  favored  the  use  of  silk  or  fine  catgut. 

Paulus  yEgineta  (a.  d.  625-690)  was  one  of  the  first  to  use 
the  double  ligature;  he  passed  two  ligatures  beneath  the  ves- 
sel, which  was  then  cut  with  a  needle,  each  end  of  the  vessel 
being  closed  separately.  Jones,  in  advocating  the  use  of 
the  double  ligature,  only  revived  a  method  which  had  been 
practised  twelve  centuries  before  his  time!  Albucasis  (died 
A.  D.  1 105)  recommended  that  a  double  thread  of  silk,  or  a 
cord  used  in  instruments  of  music  (catgut),  should  be  em- 
ployed in  ligation,  especially  in  case  of  large  vessels.  The 
use  of  catgut  is  not,  therefore,  such  a  modern  practice  as 
some  seem  to  think. 

Guy  de  Chauliac  (1300- 1363)  exerted  great  influence  in 
the  domain  of  surgery  during  the  dark  ages.  He  taught  that 
the  artery  should  be  tied  at  the  end  that  was  nearer  the  heart 
or  liver.  Some  of  his  remarks  concerning  the  sects  of  his 
time  are  apropos  to-day.     He  says:    "  The  fifth  sect  is  of 

300 


Plate   XXXIX. 


5|-   --}rj^ 


^ 


N 


^ 


^ 


\ 


"^^4,^ 


Whip  Stitch. 


Herringbone  Stitch. 


y  2 


Mattress  or  Ouilted  Stitch. 


Bell  Suture. 


(Chapter  on  Sutures.) 


HISTORY   OF   LIGATURES   AND    SUTURES  3OI 

women  and  many  fools,  who  refer  the  sick  of  all  diseases  to 
the  saints  solely,  saying,  'Le  Seigneur  me  I'a  donne  ainsi 
le  nom  du  Seigneur  soit  beni.     Amen.'  " 

Leonardo  Bertapaglia  (died  1460)  passed  a  needle,  armed 
with  a  double  thread,  through  the  artery,  tying  both  liga- 
tures firmly  over  each  other.  Alfonso  Ferri  (fifteenth  century) 
claimed  that  the  best  ligature  needle  was  one  curved  only 
at  the  point,  with  eye  at  the  opposite  end;  the  point  should 
be  quandrangular,  and  the  needle  not  over  three  inches  in 
length. 

Hans  von  Gersdorf  (1517-1590),  a  German  military  sur- 
geon, applied  ligatures  in  cases  of  vessel  wounds,  but  pre- 
ferred styptics  and  cautery  for  amputations.  Ambroise  Pare 
(15 1 7-1 590)  made  free  use  of  the  ligature  in  amputations. 
But  his  great  authority  was  not  sufficient  to  secure  the  aboli- 
tion of  the  barbarous  treatment  by  styptics  and  actual 
cautery.  Such  was  the  power  of  ignorance  and  prejudice 
that  these  methods  continued  to  be  employed  at  the  Hotel 
Dieu  until  the  time  of  Dionis  (17 18).  Pare  was  the  first  to 
use  the  twisted  suture  in  hare-lip. 

Fabricius  von  Hilden  (i 560-1634)  is  said  to  have  intro- 
duced the  use  of  the  ligature  into  Germany.  Hemp  was  the 
material  employed  by  him.  In  England  the  ligature  did  not 
come  into  common  use  until  some  time  after  Harvey's  great 
discovery  of  the  circulation  of  the  blood  (1619),  although 
introduced  some  years  before  by  Wiseman  (1566-1625).  A 
surgical  treatise  by  Peter  Lowe,  published  in  London  (1596), 
is  the  first  English  work  to  mention  ligatures. 

The  old  surgeons  were  haunted  by  the  fear  that  the  liga- 
ture would  cut  through  the  walls  of  the  artery.  Many  de- 
vices were  employed  to  prevent  such  accidents.  Lorenz 
Heister  (1683- 1758)  used  a  stout  ligature  tied  over  a  small 
cylinder  of  lint.  All  kinds  of  substances  have  been  used  for 
ligatures  in  an  effort  to  secure  a  ligature  that  would  not  pro- 
duce the  ill  effects  of  the  ordinary  ligature.    The  old  German 


302  THE  SURGERY  OF  THE  LUNGS 

surgeons  used  hemp  or  linen  ligatures.  These  substances  are 
coming  in  use  again;  the  French  are  making  extensive  use 
of  hemp  in  the  Parisian  hospitals.  P.  F.  von  Walther  was 
the  first  to  propose  the  use  of  silk  in  Germany;  but  before 
Lister's  great  discovery  all  kinds  of  material  proved  more 
or  less  unsatisfactory. 

The  use  of  the  animal  ligature  was  introduced  in  America 
by  Dr.  Physick  in  1814.  McSweeny  brought  the  employment 
of  silk-worm  gut  for  ligatures  into  prominence  in  181 8,  al- 
though Wardorp  had  used  it  some  years  earlier.  Sir  Astley 
Cooper  believed  that  catgut  would  give  the  best  results.  Dr. 
H.  S.  Levert,  of  Mobile,  used  elastic  rubber  rings.  He  also 
experimented  with  hgatures  made  of  various  metals.  He 
secured  primary  union  in  every  case  in  which  he  used  metallic 
ligatures,  or  rather,  metallic  sutures.  The  expressions  used 
seem  to  indicate  that  he  sewed  wounds  with  wire. 

Human  hair  was  used  by  Porta.  Paul  Eve  made  use  of 
the  fibres  of  the  tendons  of  deer.  Dr.  Stone,  of  New  Orleans, 
tied  the  common  iliac  artery  with  a  metallic  ligature  in  1859, 
and  afterward  he  tied  the  femoral.  Mr.  Barwell  used  liga- 
tures made  of  the  aorta  of  the  ox.  He  tied  the  ligature  only 
tight  enough  to  approximate  the  intima.  Dr.  Ishigaro,  a 
Japanese  army  surgeon,  used  a  ligature  made  from  the  tendon 
of  a  whale. 

Marcy  (1871)  used  kangaroo  tendon  for  buried  sutures, 
while  Mr.  Croft,  in  1881,  used  it  for  ligatures.  He  tied  the 
external  iliac  artery  with  kangaroo  tendon  during  that  year. 

Until  the  end  of  the  eighteenth  century  the  ends  of  the 
ligature  were  brought  out  through  the  wound.  The  practice 
of  cutting  the  ends  short  is  due  to  the  efforts  of  Lawrence, 
although  it  is  said  that  Haire,  of  Essex,  had  practised  this 
procedure  in  1786.  Lawrence  used  dentist's  silk  for  Hga- 
tures. An  American  naval  surgeon,  however,  in  1798,  adopted 
the  practice  of  cutting  short  the  ends  of  the  knot.  For  many 
years  it  was  held  that  it  was  the  division  of  the  two  inner 


HISTORY   OF   LIGATURES   AND    SUTURES  303 

coats  of  the  artery  which  caused  the  adhesive  inflammation 
that  obliterated  the  vessel.  Antonio  Scarpa  (1747-1832) 
proved,  however,  by  his  experiments,  that  the  division  of 
the  coats  of  the  artery  was  not  necessary  to  produce  this 
adhesive  inflammation. 

The  search  for  a  material  that  would  give  the  best  possi- 
ble results  as  a  ligature  has  been  the  "  Philosopher's  Stone  " 
to  surgeons.  The  good  results  that  follow  the  use  of  a 
strictly  aseptic  ligature  have  been  apparent  to  all,  but  animal 
ligatures  are  claimed  by  some  to  be  the  ligature  par  excellence, 
while  others  say  that  silk  or  silk-worm  gut,  or  metallic  liga- 
tures are  the  best.  Again,  others  say  that  any  absorbable 
ligature  will  produce  good  results,  while  still  others  pin  their 
faith  to  non-absorbable  ligatures.  Silk  and  hemp  have  been 
objected  to  on  the  ground  that  they  are  liable  to  produce 
suppuration.  Since  the  discoveries  of  Lister,  Pasteur,  and 
Koch,  such  objections  have  lost  all  force. 

The  claim  has  been  made  in  behalf  of  animal  ligatures 
that  they  resemble  in  structure  tire  tissues  in  which  they  are 
placed.  For  this  reason  they  are  the  best  for  permanent 
ligatures,  and  also  because  the  continuity  of  the  vessels  is 
not  necessarily  destroyed.  The  extra-vascular  cicatrix  is 
also  strengthened.  By  the  use  of  the  animal  ligature  the 
internal  tunics  of  the  artery  remain  intact,  yet  cicatrization 
occurs;  hence  they  need  to  be  tied  with  only  sufficient  force 
to  approximate  the  surfaces  of  the  intima.  All  that  can  be 
said  in  favor  of  the  animal  Hgature  or  suture  has  been  found 
true  with  kangaroo  tendon,  but  catgut  is  not  reliable.  There 
is  great  difficulty  in  securing  catgut  than  can  be  thoroughly 
sterilized  or  that  will  stay  where  it  is  placed,  or  that  will  not 
break  at  the  most  inopportune  time. 

There  are  other  objections  to  the  use  of  catgut.  It  has 
been  claimed  for  catgut  that  it  will  not  divide  the  tunics  of 
an  artery.  Both  Brun  and  Stimson  proved  by  their  experi- 
ments that  it  will  divide  the  tunics.     Stimson  adds  that  the 


304  THE  SURGERY  OF  THE  LUNGS 

adventitia  also  gives  way  under  the  pressure  of  the  hg- 
ature. 

Mr.  Barwell,  who  introduced  the  use  of  hgatures  made 
from  the  aorta  of  the  ox,  claims  that  this  material  is  not  ab- 
sorbed, but  becomes  organized  and  forms  an  integral  part 
of  the  neighboring  tissues.  Dent  claims  that  his  experience 
with  ligatures  of  this  material  corroborates  that  of  Barwell. 
Lister,  however,  thought  they  had  misinterpreted  the  process 
observed.  One  prominent  surgeon  says,  in  reference  to  non- 
absorbable ligatures,  that  "  all  Hgatures,  however,  which 
permanently  resist  absorption,  destroy  the  continuity  of  the 
vessels  and  weaken  the  vessel-walls  at  the  seat  of  ligation." 
Silk  when  used  for  Hgatures  does  net  cause  this  injury  to 
the  artery,  but  is  partly  absorbed  and  finally  encysted,  first 
being  infiltrated  with  new  cellular  elements. 

It  is  true  that  non-absorbable  ligatures,  if  aseptic,  remain 
in  the  wound  and  become  encysted,  but  it  is  not  true  that 
they  are  prone  to  destroy  the  continuity  of  the  vessel-walls. 
Sometimes  the  adventitia  is  constricted  to  such  a  degree  that 
vitality  is  suspended.  In  such  cases  the  inner  tunics,  if 
healthy,  are  transformed  into  connective  tissue,  forming  a 
band  that  closes  the  vessel.  Under  these  circumstances  the 
adventitia,  after  a  slow  process  of  disintegration  and  al^sorp- 
tion,  is  replaced  by  new  cellular  elements  that  are  finally  con- 
verted into  similar  tissue.  There  is  nothing  in  these  two 
processes  that  would  interfere  with  the  continuity  of  a  vessel. 

A  well-known  surgeon  of  great  experience  says  that  in- 
jured veins  are  very  liable  to  become  infected.  If  this  state- 
ment be  true  (and  there  is  no  reason  to  doubt  it),  every  pre- 
caution should  be  observed  to  secure  asepsis.  At  least  every 
instrument  or  object  used  in  operating  and  in  dressing  the 
wound  must  be  thoroughly  sterilized.  Special  care  should  be 
exercised  to  have  whatever  material  is  employed  in  ligating 
or  suturing  perfectly  aseptic. 

In  addition  to  ligatures  there  are  various  methods  to  se- 


Plate  XL. 


W 


Combination  of  Mattress  and 
Continued  Stitches. 


Tug  Stitch. 


Combined  Tug  and  Tobacco 
Pouch  Stitch. 


Glover's  Suture. 


(Chapter  on  Sutures.) 


HISTORY   OF   LIGATURES  AND   SUTURES  305 

cure  bleeding  vessels.  Torsion  and  acupressure  are  the  two 
principle  modes,  but  neither  is  reliable.  Torsion  vessels  will 
give  way  to  a  very  slight  increase  of  pressure,  about  six  and 
one-half  pounds;  vessels  closed  by  acupressure  will  stand  an 
increase  of  about  twelve  to  fifteen  pounds  to  the  square  inch. 
But  both  methods  would  be  useless  in  certain  cases,  especially 
in  the  lungs. 

Pollard,  in  1869,  devised  a  method  similar  to  acupressure. 
He  substituted  a  silver  wire  for  the  ligature,  and  brought 
the  ends  out  through  the  skin  covering  the  edges  of  the 
wound;  the  ends  were  then  twisted  together. 

Two  other  methods  are  of  historical  interest.  R.  X.  Smith 
passed  a  wire  (iron)  through  a  silver  tube  to  constrict  the 
vessels.  Six  hours  were  sufficient  to  secure  obliteration  of 
fourth  and  fifth  size  arteries,  and  two  days  for  the  large  vessels 
(femoral  artery).  Fabricius,  however,  anticipated  Smith  in 
the  use  of  iron  wire ;  about  the  middle  of  the  seventeenth 
century  he  recommended  that  an  iron  wire  should  be  used 
for  ligation.  One  end  of  the  wire,  which  had  been  tempered, 
was  to  be  sharpened  and  used  as  a  needle. 

The  so-called  filo-pressure  method  was  introduced  in  1868 
by  Brun.  A  silk  ligature,  which  had  been  passed  around 
an  artery,  was  brought  out  of  the  wound  through  a  silver 
cannula  having  a  cross-bar,  the  silk  being  fastened  to  the 
cross-bar.  This  method  was  used  by  Brun  in  his  clinic  for 
six  years,  and  he  claimed  that  it  was  perfectly  satisfactory. 

There  have  been  disputes  also  concerning  the  proper 
material  to  use  for  sutures.  At  this  time  there  can  be  no 
question  of  the  advisability  of  the  closure  of  wounds  with 
sutures.  Now,  only  a  smile  of  amusement  is  provoked  by 
statements  like  Velpeau's,  "  if  the  employment  of  the  suture 
.  .  .  was  not  necessarily  accompanied  with  much  severe 
pain;  if  the  union  of  the  teguments  was  the  most  im- 
portant part  of  the  operation  .  .  .  (sutures)  would  have 
been  long  ago  adopted    .    .    .     [the  objections  omitted],  in- 


306  THE  SURGERY  OF  THE  LUNGS 

duces  US  to  believe  that  for  the  future,  except  in  a  small 
number  of  cases,  the  adhesive  plasters  will  continue  to  be 
substituted. 

There  have  been  many  efforts  directed  toward  securing 
a  material  that  would  give  satisfaction.  It  is  not  held  by 
anyone  to-day  that  any  particular  material  is  the  cause  of 
suppuration,  although  the  ordinary  explanation  of  the  cause  of 
infection  may  not  be  accepted.  All  will  admit  the  good 
effects  following  the  employment  of  aseptic  material  in  sutur- 
ing. Catgut  has  its  advocates  for  suturing,  who,  as  a  rule, 
insist  more  strongly  on  it  being  the  best  material  for  suturing 
than  for  the  ligature;  but  all  that  has  been  said  against  its 
use  as  a  ligature  holds  true  as  regards  a  suture.  Even  greater 
objections  can  be  urged  against  its  use. 

The  use  of  wire  or  animal  material  for  suturing  is  not  alto- 
gether a  new  thing.  Fabricius,  of  Aquapendente  (1647), 
recommended  metallic  sutures.  The  other  Fabricius  (1537- 
1619),  a  century  earlier,  in  referring  to  intestinal  wounds, 
speaks  of  animal  sutures.  The  systematic  use  of  animal,  or 
rather  catgut  sutures,  is  said  to  have  been  due  to  Lister. 

John  Morgan  (1797-1847)  is  said  to  have  been  the  first 
to  employ  metallic  sutures.  (Dennis's  "  System  of  Surgery," 
Vol.  I,  1895.)  A  London  surgeon,  Mr.  Gossett,  in  1834, 
used  silver-gilt  wire  for  suturing  in  a  case  of  vesicovaginal 
fistula.  The  publication  of  the  results  of  Sir  J.  Simpson's 
experiments  on  animals  drew  attention  to  the  use  of  metallic 
sutures  in  this  country.  Dr.  J.  Marion  Sims  employed  metallic 
sutures  in  1849.  He  is  said  to  have  been  the  first  to  use 
them  in  America. 

The  use  of  metal  for  this  purpose  has  been  condemned, 
but  like  all  non-absorbable  material,  silk-worm  gut,  et  castera, 
metallic  sutures  do  no  harm.  In  some  cases  they  are  of 
great  utility  in  preventing  after  trouble.  It  is  only  in  a  few 
positions  that  metallic  sutures  could  cause  any  inconvenience. 
Silk  or  wire  very  rarely  cause  trouble  by  working  out  to  the 


HISTORY   OF   LIGATURES   AND    SUTURES  3O7 

surface.  The  most  important  point  in  their  favor  is  that 
they  can  be  perfectly  steriHzed. 

In  a  work  deahng  with  the  surgery  of  the  lung  it  may 
be  of  interest  to  give  an  account  of  certain  methods  that  have 
been  used  to  secure  arteries  of  the  chest,  especially  the  inter- 
costal. Goulard,  of  Montpelier,  invented  a  special  needle  for 
this  purpose.  This  needle  formed  three-fourths  of  a  circle, 
with  the  eye  near  the  point,  which  was  somewhat  blunt.  The 
ligature  lay  in  the  concavity  of  the  needle;  to  facilitate  its  use, 
the  needle  was  attached  to  a  long  handle.  Lottery,  of  Turin, 
constructed  for  this  purpose  a  steel  plate,  which  was  narrower 
at  one  end  than  at  the  other;  at  the  narrow  part  it  curved  in 
two  directions.  Holes  were  punctured  in  the  curved  part  of 
the  plate,  to  fasten  the  compress  for  the  artery.  The  instru- 
ment was  secured  by  narrow  strips  of  cloth  which  passed 
through  slits  in  the  broad  end  of  the  plate.  The  plate  was 
introduced  into  the  wound  in  such  a  manner  that  the  lower 
edge  of  the  rib  rested  in  the  concavity  of  the  plate,  and,  of 
course,  the  compress  acted  on  the  edge  of  the  rib  and  artery. 

Quesnay  employed  a  piece  of  ivory  covered  with  lint. 
The  instrument  was  drawn  from  within  outward,  compress- 
ing the  artery  by  means  of  a  ribbon.  Belloc  also  invented 
an  instrument  for  the  same  purpose.  It  consisted  of  two 
plates,  padded,  which  could  be  approximated  by  a  screw. 


CHAPTER   V 

PNEUMONOTOMY— PNEUMONECTOMY— PNEUMONOR- 
RHAPHY  —  PNEUMONOPEXY  —  BRONCHOTOMY  — 
GENERAL   AND    LOCAL    AN^STHESL\ 

Pneumonotomy  is  a  compound  Greek  word.  7n/ei;/iO)j/  to^tj, 
meaning  a  cutting  of  lung.  It  is  more  descriptive  and 
should  supplant  all  other  words  for  cutting  operations  upon  the 
lung.  Pneumotomy,  pneumonectomy,  and  various  other 
terms  and  expressions  have  been  applied,  but  not  until  1890 
was  the  word  pneumonotomv  adopted,  and  then  by  De  For- 
rest Willard.  Since  that  time  it  has  only  been  occasionally 
used  by  various  operators  for  the  opening  of  cysts  and  ab- 
scesses. 

Pneumonectomy  means  the  removal  of  a  part  or  all  of  one 
or  more  lobes  of  the  lung.  It  is  resorted  to  in  many  cases 
of  laceration,  new  growths,  hernia,  and  gangrene  of  the  lung. 

PueumonorrJiaphy  (suturing  the  lung)  has  been  success- 
fully accomplished  many  times  for  injuries  and  after  opera- 
tions, for  the  removal  of  foreign  bodies,  hernia,  gangrene, 
cysts,  and  new  growths.  Absorbable  and  non-absorbable 
sutures  are  either  absorbed  or  become  encysted  in  the  lung 
tissue,  so  that  one  need  not  hesitate  to  use  sutures  of  any 
accepted  material  in  emergency  surgery  of  the  lung. 

Pneiimonopexy  (anchoring  the  lung  to  the  chest  wall)  is 
sometimes  desirable  in  dealing  with  the  lung  stump  after 
amputation  for  hernia  or  laceration,  or  after  an  abscess  or 
cyst  has  been  opened  for  drainage;  also  where  there  is  doubt 
as  to  securing  pulmonary   vessels   in   injuries  or  operations 

308 


PNEUMONOTOMY — GENERAL   AND    LOCAL   AN^STIIESL\      309 

upon  the  lung.  There  are  but  few  cases  where  it  would  proba- 
bly be  best  to  anchor  the  lung  to  the  chest  wall,  thus  re- 
quiring two  sittings  for  opening  cysts  or  abscesses. 

Bronchotomy  (cutting  into  the  bronchus)  is  done  for  the 
removal  of  foreign  bodies  and  polypi.  The  point  of  attack 
may  be  through  the  anterior  or  posterior  chest  wall.  This 
is  one  of  the  most  difficult  operations  of  the  lung,  because 
the  lung  itself  must  be  divided  before  the  bronchus  can  be 
opened. 

Historical  (1714-1903).  —  Fabricius  Hildanus  (Opera 
omnia.  Francof.  A.  M.,  1646)  and  Ruysch  (Opera  omnia. 
Amsterodami,  1737)  have  recorded  cases  in  which  large  por- 
tions of  the  lungs  have  been  excised  and  patients  recovered. 
Baglion  advocated  operations  on  the  lungs  as  early  as  1714, 
and  Barry  indorsed  the  doctrine  of  Baglion  ten  years  later. 
("Treatment  of  Consumption  of  the  Lungs,"  p.  217,  Dublin, 
1726.) 

Hale  {Medical  Exam.,  Philadelphia,  185 1)  referred  to  a 
case  of  penetrating  wound  in  the  chest  in  which  recovery 
followed  the  removal  of  a  piece  of  the  lung.  Willard  (1891) 
made  an  intrathoracic  bronchotomy  from  behind  for  a  for- 
eign body  impacted  in  the  bronchi.  Even  though  he  was 
not  permitted  to  complete  the  operation,  owing  to  the  ex- 
hausted condition  of  the  patient,  he  demonstrated  beyond 
peradventure  the  feasibility  of  the  operation  under  proper 
environments.  His  experiments  were  especially  valuable  in 
that  many  vexatious  problems  concerning  the  suturing  of 
lung  tissue  were  solved. 

One  prominent  writer  says:  "Although  some  animals 
have  survived  complete  extirpation  of  a  lung,  man  has  not." 
Although  there  is  but  one  case  recorded  where  man  has  sur- 
vived a  primary  operation  involving  the  extirpation  of  either 
the  right  or  left  lung,  there  are  many  cases  on  record  where 
one  or  the  other  of  the  lungs  has  been  destroyed  by  disease 
or  trauma  and  the  patient  has  survived.    There  are,  too,  cases 


3IO  THE  SURGERY  OF  THE  LUNGS 

lately  recorded  of  the  extirpation  of  a  lung,  but  it  is  not 
clearly  stated  whether  the  patient  recovered  or  not. 

Kurz  wrote  extensively  upon  lung  surgery.  Grumwald 
and  Manquat  each  speak  of  lung  surgery  during  the  year 
1891,  which  saw  so  much  published  concerning  surgery  of 
the  lung.  Krecke  during  the  same  year  gave  a  most  inter- 
esting history  of  lung  surgery.  Bechini  (1891)  published  a 
paper  on  the  application  of  surgery  to  the  lung  in  grave 
cases,  as  did  Roux.  Guermonprez  (1892)  described  a  new 
method  of  suturing  the  lung.  TufBer  (1892)  added  much 
to  this  special  department  of  surgery  by  his  research.  Wills 
(1892)  described  his  experimental  study  in  pneumonectomy 
and  lung  suturing.  Richerole  (1892)  mentions  "  pneumo- 
nectomie  "  in  an  address  upon  lung  surgery.  Delagnere 
(1894)  contributed  an  essay  on  his  observations  on  the  sur- 
gery of  the  pleura  and  the  superior  lobes  of  the  lung,  as 
did  Heydweiller  (1894)  in  a  work  on  the  surgery  of  the  lung. 

Rodman  (1894)  made  a  pneumonotomy.  Tuffier  (1895) 
again  mentions  a  new  method  for  the  surgical  exploration 
of  the  lungs.  Artman  (1897)  also  pubHshed  a  critique  on 
lung  injuries  and  on  the  present  status  of  lung  surgery.   Beck 

(1897)  published  his  technique  of  pneumonotomy.     Merelli 

(1898)  resected  the  pulmonary  cartilages.  For  other  ob- 
servers who  have  reported  new  methods  and  interesting  cases 
see  Bibliography. 

Karewski  (1898)  and  Kopstein  contribute  valuable 
thoughts  on  lung  surgery.  Herzfeld  (1898)  and  Mayo  (1898) 
also  reported  cases  of  pneumonotomy.  Malbot  (1898)  pub- 
lished a  paper  on  the  surgery  of  the  lung.  Kohler  (1898) 
published  a  work  on  pulmonary  surgery;  those  interested 
in  this  branch  of  surgery  will  find  this  work  very  valuable. 
Riedel  (1898)  published  his  observations  on  lung  surgery. 
Augros  published  a  paper  (1898)  on  the  treatment  of  chronic 
empyaema. 

Sonnenberg  (American  Medicine,  July,  1901)  has  formu- 


Plate  XLI. 


Anti-iracosis  IX  Cancerous  Lung. 


(Chapter  on  Foreign  Bodies.) 


PNEUMONOTOMY— GENERAL   AND    LOCAL   ANAESTHESIA      31I 

lated  the  following  law  regarding  pneumonotomy :  "If  the 
pulmonary  tissues  are  hard,  divide  them  with  a  knife,  as  there 
is  no  danger  of  haemorrhage;  if  the  pulmonary  tissues  are 
soft,  divide  them  with  the  cautery,  as  there  is  great  danger 
of  hemorrhage."  It  has  been  the  author's  experience  that 
the  use  of  the  fingers  to  divide  the  tissues  gives  the  best 
results  in  the  latter  case. 

When  pneumonotomy  or  pneumonectomy  is  undertaken 
for  tumors  or  tuberculosis,  Koenig  says :  "To  perform  such 
an  operation  the  surgeon  must  ignore  absolutely  all  his 
knowledge  of  pathology."  Tuffier,  in  his  Moscow  address, 
gives  an  analysis  of  three  hundred  and  six  pneumonotomies. 
There  were  ten  recoveries  in  fifty-five  cases  of  metapneu- 
monic gangrene;  three  in  four  cases  of  gangrene  with  ectasia 
of  the  bronchi;  two  recoveries  in  seven  cases  of  embolism; 
one  from  a  gunshot  wound.  In  forty-nine  cases  of  abscess 
of  the  lung,  mostly  encapsulated  intralobular  suppurating  pleu- 
ritis,  twenty-three  per  cent,  succumbed  to  the  pneumonotomy; 
three  cases  of  incipient  tuberculous  foci  were  cured,  but  the 
operation  in  cavities  was  followed  by  death  in  thirteen  out  of 
twenty-six  cases  operated  on. 

Ombonin  and  Michaux's  cases  were  gunshot  wounds;  De 
Lormes's  a  stab.  The  first  died  from  infection;  the  second 
from  exhaustion,  thirty  minutes  after  the  operation;  and  the 
third  made  a  perfect  recovery,  the  wound  having  been  packed 
with  gauze  to  prevent  haemorrhage.  The  open  cavities  rarely 
cicatrized,  and  only  one  or  two  were  improved.  Intra- 
parenchymatous  injection  in  tuberculosis  also  proved  inef- 
fectual. No  primary  neoplasms  have  yet  been  operated  upon, 
but  seven  cases  of  sarcoma  that  have  extended  to  the  wall 
over  the  lung  were  operated  on.  For  these  difficult  opera- 
tions he  resorts  to  trachaeal  insufflation  with  respiration  by 
pressure  through  a  tamponed  cannula  introduced  into  the 
larynx.  He  rejects  puncture  in  hydatid  cysts,  as  unreliable 
and  dangerous,  from  possible  perforation  of  the  bronchi. 


312  THE   SURGERY    OF   THE   LUNGS 

There  are  twenty-nine  operations  on  record  for  aseptic 
lesions  of  the  King,  with  twenty-two  recoveries,  seventy-five 
and  eight-tenths  per  cent.,  and  seven  deaths,  twenty-four  and 
one-tenth  per  cent.  This  includes  traumatic  lesions,  hernise, 
neoplasms,  and  tuberculous  nodules.  Sixty-one  operations 
were  performed  for  hydatid  cysts,  with  fifty-five  recoveries 
and  six  deaths.  The  remaining  two  hundred  and  fifteen  were 
performed  for  septic  lesions,  with  one  hundred  and  forty  re- 
coveries, or  sixty-four  and  eight-tenths  per  cent.;  seventy- 
five  deaths,  or  thirty-five  and  two-tenths  per  cent.  This 
includes  tuberculous  cavities,  thirty-six  cases  with  thirty- 
six  deaths;  abscess,  forty-nine  cases  with  twelve  deaths; 
bronchiectasis,  forty-five  cases  with  thirteen  deaths;  foreign 
bodies,  eleven  cases  with  four  deaths;  gangrene,  seventy- 
four  cases  with  thirty  deaths;  actinomycosis,  one  case,  not 
fatal.  Total,  three  hundred  and  six  cases;  cured,  two  hun- 
dred and  seventeen;  died,  eighty-eight.  {Journal  Amer- 
ican Medical  Association,  January  15,  1898,  p.  169,  Vol. 
XXX.) 

B.  Bell  fearlessly  and  successfully  opened  abscesses  in 
the  lung,  no  matter  at  what  depth  they  were  situated.  Sapie- 
joks  stated  that  he  located  adhesions  with  an  exploratory 
needle,  connected  with  a  manometer;  when  the  point  of  the 
needle  projected  into  an  open  space,  the  manometer  was 
lowered,  while  it  remained  stationary  if  the  needle  encoun- 
tered adhesions. 

Operative  Technique.. — Emergency.  In  this  class  may  be 
included  the  cases  of  severe  haemorrhage  (due  to  injury  or 
disease),  hernia,  foreign  bodies,  and  those  surgical  conditions 
produced  by,  or  resulting  from,  delay  in  advanced  pathologic 
changes. 

Election.  In  this  class  are  to  be  included  those  cases  in 
which  ample  time  is  given  to  analyze  conditions  and  decide 
upon  a  certain  definite  course  to  pursue. 

There  is  but  little  variation  in  the  course  to  pursue  for 


PNEUMONOTOMY — GENERAL   AND    LOCAL   AN^STHESLV      313 

the  incising  of  lung  tissue,  removal,  suturing,  or  anchoring 
to  the  chest  wall  (internally  or  externally),  so  far  as  the 
preliminary  work  for  their  performance  is  concerned.  The 
same  surgical  principles  should  be  maintained  in  asepsis, 
opening  and  closing  the  chest,  with  or  without  drainage,  to- 
gether with  the  postoperative  treatment.  The  operator 
should  prepare  for  artificial  respiration  in  all  cases  of  opera- 
tions on  the  lungs.  He  should  have  a  supply  of  oxygen  at 
hand,  with  the  necessary  apparatus  to  use  it.  He  should 
also  have  a  number  of  assistants  present,  in  case  it  should 
be  necessary  to  employ  artificial  respiration.  The  surgeon 
must  also  be  prepared  for  tracheotomy  if  other  means  fail. 
In  asphyxia  a  laryngeal  cannula  may  be  used,  with  bulb  to 
produce  strong  artificial  respiration.  (Journal  American 
Medical  Association,  January  15,  1898,  p.  169.)  It  is  well 
to  have  strychnine,  a  battery,  bellows,  hot  water,  etc.,  at 
hand,  with  means  of  rectal  divulsion. 

Pneumonotomy  is  the  only  probable  means  of  relief  in  cases 
of  hydatid  cysts,  localized  gangrene,  and  abscess.  When 
resorting  to  this  operation,  the  exact  seat  of  the  disease  is 
first  determined  by  the  usual  means.  If  adhesions  are  present, 
aspiration  is,  perhaps,  a  most  important  means.  Then  the 
superficial  tissues  are  divided  and  one  or  more  ribs  resected, 
as  may  be  necessary,  care  being  taken  not  to  injure  the  pleura. 
(In  case  of  adhesions,  it  is  the  practice  of  some  to  discard 
the  knife  and  use  actual  cautery  heated  to  a  dull  red  glow.) 
The  seat  of  the  disease  having  been  freely  laid  open,  the 
patient  is  rolled  over  to  encourage  the  outflow  of  fluid.  Drain- 
age by  gauze  or  tube  is  established  and  haemorrhage  is 
checked  by  pressure.  When  there  are  no  pleural  adhesions, 
the  operation  is  more  difficult  and  the  prospect  poor.  Sutur- 
ing the  lung  to  the  chest  wall  before  making  an  incision  of 
the  pleura  is  difficult,  and  does  not  always  prevent  partial 
pneumothorax.  Do  not  irrigate,  as  it  is  liable  to  drown  the 
patient. 


314  THE  SURGERY  OF  THE  LUNGS 

Sterilization  may  be  general,  local,  or  both.  It  is  es- 
pecially desirable  that  the  field  of  operation  be  cleansed. 
However,  there  are  cases  where  necessity  and  environment 
will  preclude  the  possibility  of  the  least  attempt  at  cleanli- 
ness, which  might  result  in  the  loss  of  a  life,  or  serious  compli- 
cations that  would  overshadow  the  benefits  to  be  derived. 
This  is  especially  the  case  when  the  internal  mammary  and 
larger  blood-vessels  have  been  injured.  If  time  is  sufficient, 
every  precaution  should  be  taken.  The  field  of  operation 
should  first  be  cleansed  with  soap,  water,  alcohol,  turpen- 
tine or  benzine,  and  not  only  the  skin,  but  the  fabrics  to  be 
used  in  the  operation  and  in  the  care  of  the  case  should 
also  be  clean. 

General  and  Local  Anaesthesia. — No  anaesthesia  is  necessary 
when  a  state  of  unconsciousness  prevails.  General  anaesthesia 
is  to  be  employed  in  emergencies  as  a  rule,  if  patient  is  con- 
scious, and  also  in  the  majority  of  cases  of  election.  Chloro- 
form is  to  be  preferred  because  narcosis  is  obtained  quickly 
and  with  less  resistance.  Local  anaesthesia  can  seldom  be 
employed  in  emergencies  owing  to  its  uncertainty  and  the 
time  required  to  be  effectual.  Ethyl  chloride  and  cocaine 
are  the  most  desirable  agents.  Local  anaesthesia  may,  how- 
ever, be  frequently  employed  in  cases  of  election. 

Opening  in  Chest.  A  curved  cutaneous  incision  (with  the 
point  of  entrance  of  the  weapon  in  the  chest  and  the  point 
to  be  attacked  in  the  centre  of  the  circle)  will  enable  one  or 
more  ribs  ro  be  divided  by  the  forceps  in  a  semicircle ;  its  extent 
and  direction  must  be  governed  by  the  necessity  for  drainage. 
Great  care  should  be  exercised  in  not  allowing  instruments 
to  enter  the  pleural  cavity  before  the  lung  has  contracted 
upon  itself,  as  the  result  of  air  entering  the  chest.  If  the 
chest  remain  open,  the  lung  will  be  contracted,  but  if  the 
opening  becomes  closed  by  clots  or  otherwise,  the  lung  will 
again  expand.  A  contracted  lung  is  desirable  at  time  of 
opening  the  chest  because  of  the  danger  of  injuring  it.     It 


Plate    XLTI. 


f  , 


■4    '•'■  ?''■■'<„- 


^J^'i»€ 


^^^>&' 


X  IT.T. 

GEdema   of   Lung. 


X  lor,. 


Poly  L- us. 
(Chapters  on  Benign  Tumors  and  CEdema.) 


PNEUMONOTOMY — GENERAL   AND    LOCAL  AN^STHESLV      315 

can  be  made  to  contract  by  reopening  the  wound  and  allow- 
ing air  to  enter  the  chest,  just  previous  to  operating. 

There  is  but  little  bleeding  in  dividing  the  soft  and  bony 
structures  of  the  chest,  unless  the  internal  mammary  artery 
is  severed.  The  intercostal  arteries  cause  but  little  annoy- 
ance. If  they  do,  they  may  be  ligated,  or  crushed  with 
forceps.  Both  the  distal  and  proximal  extremities  of  the 
internal  mammary  artery  should  be  ligated.  The  existence 
of  adhesions  of  the  parietal  to  the  visceral  pleura  is  desira- 
ble when  the  lung  is  to  be  incised  for  cysts,  or  for  the  re- 
moval of  foreign  bodies,  but  their  induction  is  not  necessary 
before  opening  the  chest. 

An  opening  in  the  chest  permitting  ample  space  for  work 
is  essential,  and  no  time  should  be  lost  in  accomplishing  it. 
All  clots  within  the  pleural  cavity  should  at  once  be  removed 
with  the  fingers,  and  gauze  used  to  keep  the  lung  clean 
until  the  wound  can  be  found.  Once  discovered,  a  pair  of 
long-handled  artery  forceps  may  be  applied.  If  the  bleed- 
ing is  not  severe,  it  may  be  controlled  by  firmly  packing  gauze 
into  the  open  wound  of  the  lung.  Either  one  of  these  pro- 
cedures will  permit  of  ample  time  to  decide  upon  the  proper 
course  to  pursue.  The  situation  well  in  hand,  a  silk  ligature 
may  be  appHed  to  the  artery,  and  a  suture  of  the  same  mate- 
rial used  to  close  the  laceration  in  the  lung  tissue,  if  it  be 
proper. 

If  the  laceration  involves  the  border  of  one  or  more  lobes, 
the  lung  may  be  brought  out  of  the  chest  cavity  and  the 
work  completed  before  it  is  returned.  The  ragged  portion 
of  the  lung  may  be  ligated  en  masse  by  transfixion,  and  the 
lung  returned  to  the  pleural  cavity.  All  bleeding  vessels 
being  secured,  the  pleural  cavity  freed  from  all  clots  and  for- 
eign material,  the  chest  may  be  temporarily  closed  for  a  few 
moments,  by  coapting  the  cutaneous  structures,  or  by  placing 
the  hand  over  the  opening  in  the  clTest  to  allow  the  lung 
to  expand,  and  to  be  assured  that  all  ligatures  are  in  their 


3l6  THE  SURGERY  OF  THE  LUNGS 

proper  places.  This  once  determined,  the  chest  can  be  at 
once  closed,  with  or  without  drainage,  as  the  case  may  re- 
quire. 

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1154- 
PiCKARD,  Canadian  Practitioner ,  Toronto,  1893,  XVIII,  433. 
Trzebicky,  Wien.  Medicin.  Woch.,  1893,  905~956- 
Pitts,  Lancet,  London,  1893,  II'  615,  678.  735,  795,  915. 
MiJLLER,    Deutsche    Zeitschr.    f.    Chirurgie,    Leipzig,    1893. 

XXXVII,  41-49. 
Delageniere,  Arch.  Prov.  de   Chirurgie,   Paris,    1894,   III, 

1-42. 
Heyweiller,  Berlin,  1894,  p.  307. 


3l8  THE  SURGERY  OF  THE  LUNGS 

Lopez,  Sigh  Medical,  Aladrid,  1894.  XLI,  198-200. 
Karotta,,  Osaka  Igakii,  Lenkukwan,  Zashi,  1894,  No.  18,  12- 

17- 
Omer,  Lyon  Med.,  LXXVI,  438. 

Rodman^  American  Practitioner  and  News,  Louisville,  1894, 
XVIII,  222. 

Llobat,  Rev.  de  Chiriirgie,  Paris,  1895,  242-245. 

Reclus,  Gazette  Hebd.,  Paris,  1895,  XLIII,  482-489. 

TuFFiER,  Semaine  Medicate,  Paris,  1895,  III.  522. 

Richard,  Semaine  Medicate,  Paris,  1895,  XV,  508. 

TuFFiER,  Gazette  d.  Hop.,  Paris,  1895,  LXVIII,  1320. 

Bloxdi,  Chirurgie,  ]\Iilano,  1895,  III.  425-459. 

Terrier,  Surgery  of  the  Lung,  F.  Alcan,  98  p. 

D'AziNcouRT,  Paris,  1896. 

RiCKETTS,  B.  ]\I.,  Clinic,  Cincinnati,  September  i,  1896,  Vol- 
ume XXXVII,  p.  22,7. 

Paget,  Surgen,^  of  the  Chest,  London,  1897;  Bull,  et  Mem. 
Societe  de  Chirurgie,  Paris.  1897,  XXIII,  76-93,  105-130. 

FuNNiN,  Suppl.  d.  Policlin.,  Roma,  1897,  1898,  IV,  1309- 
1312. 

Fuxxix,  Med.  Mod.,  Paris,  1897,  VIII,  521-524. 

Altman,  Vrtjsch.  Gerich  Med.,  1897,  XIV,  Suppl.,  71-106. 

Hadra,  Vernadi.  d.  Chirurgie,  1898,  XXVII,  pt.  L,  80-89. 

Doyen,  Revue  d.  Therap.  Med.-Chir.,  Paris,  1898,  LXV,  37^ 

43- 
Tait,  Medical  Neii's,  New  York,  1898,  LXXII,  263-266. 
Karewski,  Arch.  Klin.  Chirurgie,  1898,  LVII,  555  590. 
KopsTEix,  Lasop.  lek.  cesk.  v.  Prage,  1898,  XXXVII,  345-349. 
Herzfeld,  Deut.  Med.  Woch.,  1898,  p.  193. 
Mayo,  North  Western  Lancet,  St.  Paul,  1898,  XVIII,  441. 
Malbot,  Arch.  prov.  d.  Chirurgie,  Paris,  1898,  VII,  707-724. 
KoHLER,  Berlin  Klin.  Woch.,  1898,  337-341. 
RiEDEL,  Miinch.  Med.  Woch.,  1898,  p.  888. 
AuGROS,  Lyon  Med.,  1898,  p.  76,  No.  94. 
LiciiTENAUER,  Dcutsche  Zeitschr.  f.  Chirurgie,  1898-99,  I, 

389-394. 


Plate  XLIII. 


X  llo. 
LYMPHOMy\. 


♦     •      %      M 


X  250. 
ClIRONDROMA. 


(Chapter  on   Benign  Tumors.) 


PNEUMONOTOMY — GENERAL   AND    LOCAL   ANESTHESIA      319 

Solomon^  Revue  de  Chirurgic,  Paris,  1899,  XIX,  p.  284. 

Murphy,  XIII  Cong.  Internat.  de  Med.,  sect.  de.  Chir.  Gen. 
1900,  Paris,  1901,  Coiiipt.  rend.,  595-598. 

TuFFiER,  Gangrene  piilmonaire,  pneumonotomie,  apparition  de 
bacilles  turberciileux  dans  les  crachats  au  cours  du  traite- 
ment,  guerison  sans  symptomes  de  tuberculose  pulmonaire 
depuis  un  an.  Bull,  et  mem.  Soc.  de  Chir.,  Paris,  1900, 
XXXI,  342. 

Jordan,  A.,  Rev.  Vol.  de  cien.  Med.  Valencia,  1900,  II, 
72-78. 

Cristovitch,  M.,  Pneumotomie  avec  resection  costale  pour 
plaie  grave  du  poumon  par  arme  a  feu,  guerison.  Rev. 
Med.-Pharm.,  Constant,  1900,  XIII,  85-86. 

Jacobson,  O.,  Therap.  d.  Gegenwart,  Berlin,  1900,  III,  305^ 
312. 

Lane,  G.,  A  plea  for  early  operation  in  cases  of  undoubted 
tubercle  of  the  lung.     Lancet,  London,  1900,  II,  134-135. 

Rose,  Ein  fall  von  zerreissung  der  lunge  des  herzbeutels  und 
des  zwerchfells  (Haematopneumothorax  pneumopericar- 
dium und  pneumoperitoneum).  Deutsch  med.  Woch., 
Leipz.  u  Berlin,  1900,  XXVI,  ver-beil,  186. 

Herczol,  E.,  Wien.  Med.  Presse,  1900,  XLI,  2321-2324,  2375, 

2379 ;  I  %• 

TuFFiER,  Pneumotomie  pour  ectasies  bronchiques  multiples. 

Bull,  et  Mem.  soc.  de  Chir.  de  Paris,  1900,  XXVI,  242, 

243,  247,  249. 
Koch,  C.  F.  A.,  Enkele  gevallen  von  pneumotomie  Nederl. 

Tijdechr  v.  Genessk.,  Amsterdam.,  1900,  2  R,  XXXVI,  d. 

2,  911-925;  4  fig. 
Stade,  Fritz,  Inaug  Diss.,  Kiel,  1900,  Juni  u.  Juli. 
Herman,  M.  W.,  Prezgl  lek.,  Krakow,  1900,  XXXIX,  317- 

318. 
Herman,  M.  W.,  Gazz.  Med.  di  Torino,  1900,  LI,  668-673. 
Meyer,  Paul,  Gazs.  Med.  di  Torino,  1900,  LI,  709-715. 
Parascondolo,  C,  Arch.  Internal,  di  med.  e  chir.,  Napoli, 

1900,  XVI,  419-448,  449-492. 


320  THE   SURGERY   OF   THE   LUNGS 

Kareswki,  Verhandl.  d.  zver  f.  inn.  Med.  mi  Berlin,  1900,  XIX, 
192-195. 

W.  H.,  The  surgery  of  the  tuberculous  lung.  Polyclin.,  Lon- 
don, 1900,  II,  347-348. 

VuLLiET,  H.,  Gangrene  pulmonaire,  pleurotomie  et  pneumon- 
otomie.    Rev.  med.  de  la  Suisse  Rom.,  Geneve,  1900,  XX, 

67-73- 

Macalister,  C.  J.,  Puncture  of  the  lung  in  chronic  pneu- 
monic conditions.  Liverpool  Med.  Chir.  Jour.,  XXI, 
16-20. 

Weinberger,  M.,  Ztschr.  f.  Heilk.,  Wien  u.  Leipsic,  1901,  n.f. 
II,  Med.  int.  78-104,  5  taf.,  i  abb. 

Barbieri,  p.,  XIX  An.  de  San.  mil.  Buenos  Aires,  1901,  III, 

38-54. 

Delageniere,  H.,  Du  pneumothorax  chirurgicale ;  ses  dangers 
et  sa  valeur  au  point  de  vue  de  la  chirurgie  pleuropulmo- 
naire  d'apres  six  observations.  Arch.  prov.  de  Chir.,  Paris, 
1 90 1,  X,  709-727. 

BoRCHERT,  F.,  Arch.  f.  Klin.  Chir.,  Berlin,  1901,  LXIII, 
400-463. 

BoRCHERT,  F.,  Inaug.  Diss.,  Berlin,  1901,  Marz-Juni. 

Samland,  F.,  Zur  operativen  behandlung  der  granulose  unter 
besonderer  beriicksichtigung  der  gegen  dieselbe  gemach- 
ten  einwande  und  der  rezidivfrage.  Inaug.  Diss.,  Leipzig, 
1 90 1,  November. 

Karewski,  Med.  IVoch.,  Berlin,  1901,  II,  324-327. 

Semprun,  Oto-ribo-laringol  espan.,  Madrid,  1901,  IV,  9-13. 

BuLLARD,  Atlanta,  Georgia,  Journal  Record  of  Medicine,  De- 
cember, 1 90 1. 

Rose  and  Careless,  Surgery,  1901. 

Morrison,  Charlotte  Medical  Journal,  North  Carolina,  Decem- 
ber, 1 90 1. 

AiME,  Paul  Heineck,  Medical  Standard,  Chicago,  111.,  De- 
cember, 1 90 1. 

Lenhartz,  Medicin.  et  Chirurgie,  Jena,  1901,  IX,  3,  p.  338. 

Garre,  Medicin.  et  Chirurgie,  Jena,  1901,  IX.  3  p.,  338. 


PNEUMONOTOMY — GENERAL   AND    LOCAL   AN^iSTlIESIA      32  I 

Lemke^  American  J  our.  of  Surgery  and  Gyn.  St.  Louis,  Janu- 
ary, 1902. 

LeBoutillier,  Nezv  York  State  Journal  of  Medicine,  January, 
1902. 

DoLLiNGER^  J.,  Der  artificielle  pneumothorax  als  vorbereitende 
operation  zur  extirpation  durchgrei fender  brustwandtu- 
moren  oder  Lungentumoren.  Centralhl.  f.  Chir.,  Leipsic, 
1902,  XXIX,  82-83. 

Delageniere,  H.,  Du  pneumothorax  chirurgical;  ses  dangers 
et  sa  valeur  au  point  de  vue  de  la  chirurgie  pleuro-pul- 
monaire  d'apres  deux  observations.  Paris,  I.  B.  S.,  1902, 
19  p. 

Garre  u  Sultan,  Kritscher  bericht  iiber  20  Lungenopera- 
tionen  aus  der  rostocker  und  der  Koeniksberger.  Klinic 
Beitr.  s.  Klin.  Chir.,  Tiibingen,  1902,  XXXII,  492-531. 

Packard  and  Le  Conte,  American  Journal  of  Medical  Sci- 
ence, March,  1902,  p.  375. 

Huber,  Philadelphia  Mcdicin  Journal,  May,  1902,  p.  803. 

Settimi,  Gazette  Med.  di  Roma,  April,  1902,  p.  197. 

Ungar,  Zeitschrift  fiir  Medical  Beamte,  Berlin,  XX,  12  p. 
417. 

KoRTEWEG,  T.  A.,  Annals  of  Surgery,  Philadelphia,  Pa.,  July, 
1902,  p.  I. 

RiY.G'i^-ER,  Deutsche  Med.  Woch.,  Berlin,  July,  1902,  p.  515. 

Garre  and  Sultan,  Deutsche  Arch.  f.  Klin.  Chirurgie,  1902, 
XXX,  ii. 

Theodoroff,  S.  p.,  L'echinococcotomie  transpleural  d'apres 
leprofesseur  Bobroff.  Chirurgia,  Moskwa,  1902,  XI,  285- 
292. 


CHAPTER  VI 
GUNSHOT,    LACERATED   AND    INCISED   WOUNDS 

GUNSHOT  WOUNDS — Injuries  of  the  lungs,  due  to  gun- 
shot and  explosive  missiles,  are  more  common  than  those 
of  any  other  type,  and  their  character  has  changed  materially 
within  the  last  twenty-five  years.  The  quality  of  the  ex- 
plosive, the  kind  of  weapon,  the  size,  quality,  shape,  and 
velocity  of  the  ball,  have  all  undergone  a  great  evolution. 
The  ball  is  smaller,  harder  or  softer,  travels  further  and  faster, 
so  that  its  destruction  to  soft  tissues  is  greater  or  less  than 
formerly.  If  the  ball  is  harder,  the  destruction  is  less;  if 
softer,  the  destruction  is  greater  under  the  same  circum- 
stances. The  velocity  and  distance  being  so  greatly  increased 
cause  the  ball  to  become  heated  to  such  a  degree  as  to  make 
it  aseptic  at  the  time  it  comes  in  contact  with,  and  continue 
so  until  after  it  has  left  the  body.  In  consequence  of  this 
heat  the  walls  of  the  tract  through  which  it  has  passed  are 
also  made  aseptic. 

The  small  modern  steel  ball  has  been  known  to  pass 
through  every  organ,  including  the  heart  and  brain,  with- 
out producing  death.  The  kidneys,  lung,  liver,  spleen,  and 
pancreas  have  each  been  perforated  in  such  a  manner  without 
fatality. 

Historical — One  of  the  earliest  accounts  of  such  wounds 
is  that  of  Mallet  (1743),  who  published  a  report  of  a  lad  who 
was  shot  through  the  lung.  Rigby  (1790)  reported  a  case 
of  recovery  after  a  ball  had  passed  through  the  lung. 

In  1800  Home's  very  satisfactory  account  appeared.     This 

322 


GUNSHOT,    LACERATED   AND   INCISED   WOUNDS  323 

was  a  case  of  a  person  who  was  shot  through  the  lung  and 
survived  for  thirty-two  years.  The  account  contained  a 
description  of  the  appearance  of  the  contents  of  the  thorax 
after  death. 

Keys  (1845)  reports  a  case  where  balls  perforated  the 
diaphragm  and  left  lung  in  two  places.  Campbell  (1846-47) 
had  a  case  of  gunshot  wound  of  the  lung,  in  which  the  patient 
recovered.  Moore  (1847)  tells  us  of  a  case  where  the  ball 
was  lodged  fifty  years  in  the  lung.  Beal  (1847)  observed  a 
case  of  gunshot  wound  where  a  portion  of  the  right  clavicle 
was  carried  away,  and  the  bullet  passed  through  the  summit 
of  the  lung  and  scapula;  the  patient  recovered.  Eve  re- 
ported the  well-known  case  of  General  Shields,  who  was  shot 
through  the  body  by  a  grape-shot  at  Cerro  Gordo.  In  this 
case  the  grape-shot  had  evidently  entered  the  right  nipple, 
passed  between  the  lungs,  through  the  mediastinum,  and 
emerged  a  little  to  the  right  of  the  spine.  Longmore  (1855) 
also  reported  a  recovery  from  a  severe  injury  to  the  chest 
and  wound  of  the  lung  by  grape-shot.  Upshur  (1855)  re- 
ported a  case  of  gunshot  wound  of  the  lung.  Warren  (1857) 
described  a  case  where  pistol  balls  were  suspended  within 
the  chest  by  the  pleura;  also  the  appearance  of  the  thoracic 
cavity  eight  years  after  the  gunshot  wound.  Peters  (i860) 
had  a  case  of  severe  gunshot  wound  of  the  left  lung,  in  which 
the  patient  recovered. 

In  1 861  the  treatment  of  gunshot  wounds  of  the  lung 
was  given  an  impetus  by  Clapp's  publication  of  cases  of  gun- 
shot wounds  of  the  right  lung  and  their  treatment.  The 
same  year  Sinn  reported  a  case  of  gunshot  wound  of  the 
right  lung  with  discharge  of  pieces  of  lead  from  the  mouth, 
seven  weeks  after  the  injury;  recovery  took  place.  Farns- 
worth  (1865)  had  a  case  of  gunshot  wound  through  the  chest. 
Roustan  (1865)  reported  a  case  of  gunshot  wound  of  the  lung, 
in  which  the  lead  ball  became  encysted.  Forments  ( 1866)  had 
a  case  of  gunshot  wound  penetrating  the  left  lung;  the  ball 


324  THE  SURGERY  OF  THE  LUNGS 

remained.  There  was  apparent  recovery,  with  recurrence  of 
symptoms  two  years  after  the  injury. 

Johnson  (1867)  noted  the  absence  of  symptoms  in  a  case 
of  gunshot  wound  through  the  bottom  of  the  lung.  Eve 
(1867)  reported  a  case  of  penetrating  wound  of  the  left  lung 
in  an  infant,  the  ball  passing  near  the  heart;  the  patient  re- 
covered. (Circular  No.  3,  War  Department,  Surgeon-Gen- 
eral's Ofifice,  August  17,  1871,  may  be  consulted  for  reports 
of  cases  of  penetrating  gunshot  wounds  of  the  chest  with 
recovery.)  Woodson  had  a  case  of  gunshot  wound  of  the 
right  lung  and  shoulder  joint.  Wright  reported  a  case  of 
bullet  wound  of  the  right  lung  in  a  child  three  and  one-half 
years  old.  (An  interesting  w-ork  on  this  subject  is  that  of 
Chaplain  on  Lung  Wounds  by  Firearms.)  Keller  (1874)  re- 
ported a  gunshot  wound  of  both  lungs,  and  Lewis  (1874) 
reported  a  case  of  gunshot  wound  of  the  left  lung,  produc- 
ing large  pleural  efifusion;  paracentesis  thoracis  was  performed 
by  the  aspirator,  followed  by  free  incision  of  the  chest  wall 
and  convalescence  of  the  patient. 

Crawford  (1879)  reported  successful  treatment,  by  blood- 
letting, of  a  gunshot  wound  of  the  chest,  involving  both  lungs, 
and  complicated  wdth  fracture  of  the  scapula,  with  paralysis 
of  the  left  arm.  Ombonin,  of  Cremona  (1885),  De  Lormo 
(1893),  and  Michaux  (Congres  Franqais  de  Chirurgie,  1895), 
are  among  the  first  to  report  pneumonotomies  for  traumatic 
injuries  of  the  lungs.  Albuerne  (1890)  reported  a  case  of 
gunshot  wound  of  the  lung  which  healed  by  first  intention. 
Hauson  and  Coe  reported  a  case  of  gunshot  wound  of  the 
lung  in  which  septicaemia  occurred  and  was  treated  by  re- 
section of  the  rib;  recovery  follow^ed.  Macwatt  (1891)  re- 
ported two  cases  of  severe  gunshot  wound  of  the  lung  in  which 
the  treatment  resulted  in  recovery.  Bickle  (1891-92)  re- 
ported a  case  of  gunshot  wound  of  the  right  lung,  and  Gonda 
(1891)  had  a  case  of  gunshot  wound  of  the  lung  with  fistula 
remaining.  Pinquard  (1893)  also  reported  a  case  of  gunshot 
wound  of  the  lung.     Wilson  (1897)  reported  a  case  where 


Plate  XLIV. 


X  180. 
Osteoma. 


X  180. 
Dermoid  Cyst. 


(Chapter  on  Benign  Tumors.) 


GUNSHOT,    LACERATED   AND   INCISED    WOUNDS  325 

three  links  of  a  trace-chain  passed  through  the  lung,  and  Da 
Costa  (1898)  reported  a  case  of  gunshot  wound  of  the  lung. 

Hermetically  closing  the  chest  was  suggested  by  Pare, 
Larrey,  La  Motte,  and  again  in  1863  by  Dr.  Benjamin  How- 
ard, just  before  the  battle  of  Gettysburg,  after  which  a  report 
of  .sixty-seven  cases  so  treated  for  injured  lung  is  found. 
Twenty-five  recovered  and  forty-two  died.  Fifteen  out  of 
the  forty-two  were  found  upon  autopsy  not  to  have  received 
lung  injuries.  In  the  absence  of  statistics,  it  is  safe  to  say 
that  the  same  per  cent,  of  those  that  recovered  did  not  have 
lung  injuries.  It  is  also  probable  that  the  same  rule  could 
be  applied  to  all  chest  wounds,  viz.:  that  only  about  thirty 
per  cent,  of  undetermined  chest  wounds  do  not  involve  the 
lungs. 

Dr.  Orpheus  Evert  (Assistant  Surgeon  Twenty-second 
Indiana  Volunteers)  was  among  those  who  sealed  chest 
wounds  at  Gettysburg,  having  closed  five,  with  death  result- 
ing in  each  case.  (This  incident  was  communicated  personally 
to  the  writer.)  Only  three  recoveries  took  place  out  of  two 
hundred  chest  wounds  at  the  battle  of  Sebastopol,  treated  by 
the  administration  of  digitalis,  while  twenty-seven  recoveries 
ensued  in  one  hundred  and  twenty-seven  wounds  of  the  same 
character  among  the  English  at  the  same  battle,  treated  by 
venesection. 

These  reports,  like  all  statistics  of  this  character,  while 
very  interesting,  do  not  add  much  to  our  knowledge  of  lung 
injury,  as  many  of  them  are  injuries  of  the  chest  wall  alone. 
It  is  highly  probable  that  the  greater  number  of  recoveries 
among  the  English  was  due  to  better  care  and  skill,  and 
not  to  venesection.  Then,  too,  there  was  a  difference  in 
the  character  of  the  missile  used. 

About  sixty-two  and  a  half  per  cent,  of  the  wounds  re- 
ceived during  the  Civil  War,  United  States,  1861-64,  were 
of  the  chest,  while  sixty-five  and  one-half  per  cent,  constituted 
the  combined  chest  wounds  of  the  French  at  Sebastopol, 
the  British  in  the  Crimean  War,  1855;  Italian-French  War, 


326 


THE   SURGERY    OF   THE   LUNGS 


1859;  Austrian-French,  1859.  In  more  recent  years  the  rate 
has  been  higher  than  this,  as  shown  by  ]\IcCormac  (Sedan), 
Fischer  (Metz),  and  Beck  (Strassburg),  during  the  Franco- 
Prussian  War. 

The  upper  lobe  was  most  frequently  wounded,  the  ratio 
being  one  to  two.  Of  eight  thousand  seven  hundred  and 
fifteen  chest  wounds  (Civil  War,  1861-65),  four  hun- 
dred and  ninety-two,  or  five  and  one-half  per  cent.,  spat 
blood,  and  sixty  per  cent,  of  the  total  number  died.  Nelaton 
(These  de  Paris,  1880)  reports  eighty-six  cases  of  chest  pene- 
tration, with  twenty-two  recoveries,  without  operation.  In 
twenty  cases  he  resorted  to  puncture  or  incision  of  the  chest 
to  remove  clots;  four  died  from  haemorrhage,  without  opera- 
tion. Siege  wounds  of  the  chest  varied  from  one  to  twelve, 
and  one  to  sixteen,  while  open  field  wounds  of  the  chest 
averaged  about  one  to  twenty. 

These  percentages  have,  perhaps,  been  increased  by  im- 
proved firearms  and  workmanship.  W.  C.  Borden  {Phila- 
delphia Medical  Journal,  Vol.  VI,  No.  7,  x\ugust  18,  1900, 
p.  302)  gives  the  following  as  a  comparative  study  of  gun- 
shot injuries,  both  penetrating  and  non-penetrating  wounds 
of  the  chest  in  the  Civil  and  Spanish-American  wars.  While 
they  show  nothing  definite  as  to  lung  injuries,  they  are  ex- 
ceedingly interesting.  It  is  to  be  regretted  that  more  definite 
statements  are  not  made  concerning  lung  injuries  in  both 
private  and  public  practice. 


Civil  War: 

Non-penetrating. .  11,995 

Penetrating 8,269 

Spanish-American  War: 

Non-penetrating 

Penetrating 


20,264 


61 

53 


379)      ^ 


13.921 
99 


5.373 
13 


III 


870 


I.  E- 

—  o  . 


27.85 
II. 6 


GUNSHOT,    LACERATED   AND    INCISED    WOUNDS  327 

Ratio  of  number  of  recoveries  to  number  of  deaths,  in  war : 

Recoveries.  Deaths. 

Civil  War 6.7   i 

Franco-Prussian 8.0   i 

Spanish-American  War 14. i   i 

Anglo-Boer  War 19.0   i 

These  are  the  tables  to  January  27,  1900,  by  Captain  and 
Assistant  Surgeon  W.  C.  Borden,  U.  S.  A.,  Philadelphia  Med- 
ical Journal,  August  i8,  1900,  p.  302. 

Table  showing  the  percentage  of  mortality  in  penetrating 
wounds  of  the  chest : 


Name  of  Authority. 


Per  cent. 


French  in  Crimea 

English  in  Crimea 

French  in  Italy 

CiN-il  War  (U.  S.)...._ 

Prussians  in  Schleswig 

Danish    in  "  

Germans  in  Franco-Prussian  War.  .  . 

Japanese  in  Chinese  War 

Americans  in  Spanish-American  War. 


Chenu 

Matthew 

Chenu 

Otis 

Lofler 

Lofler 

Fischer 

Haga 

U.  S.  Gov. 


91.6 

79.2 

46.48 

62.66 

41.6 

67.2 

56.7 

34-7 

24-5 


Civil  War. 

Chest  Wounds — Total  Number. 

Q 

hi 

Undeter- 
mined re- 
sults. 

Per  cent. 
of  mor- 
tality. 

11,995  Non-penetrating.  .  .  . 
8,265  Penetrating 

5.373 

487  [8.26 
336  f 

13.921 

870 

27.85 

Spanish-American  War. 

61  Non-penetrating 

53  Penetrating  (114) 

13 

379  )        ^ 

99 

2 

II. 6 

(W.  C.  Borden,  M.D.  (Edin.),  Captain  and  Assistant  Sur- 
geon, U.  S.  A.,  in  the  Philadelphia  Medical  Journal,  August 
25,  1900,  Vol.  IV,  p.  334.) 

(For  diagnosis  and  treatment,  see  under  that  heading 
in  the  chapter  on  Lacerated  and  Incised  Wounds.) 


328  THE  SURGERY  OF  THE  LUNGS 

In  Aruvals  of  Surgery,  February,  1901,  Dr.  E.  F.  Robin- 
son, late  Acting  Assistant  Surgeon,  U.  S.  A.,  gives  his  ex- 
perience in  treating  gunshot  wounds  in  the  Phihppines.  He 
says  that  seventy-eight  cases  of  gunshot  wounds  of  the  lungs 
were  brought  to  his  hospital.  Of  these,  ten  were  dead  when 
they  arrived  or  died  within  twenty-four  hours,  leaving  sixty- 
eight  cases  that  were  treated.  Forty-four  of  the  wounds  were 
caused  by  Mauser  or  Krag  bullets,  twenty-four  by  Reming- 
ton or  revolver  bullets.  Five  of  the  forty-four  high  velocity 
wounds  were  infected.  Of  the  twenty-four  low  velocity 
wounds,  five  were  infected  and  died;  six  others  were  infected, 
but  having  been  sent  home  were  lost  sight  of.  He  claims 
that  fifty  per  cent,  of  the  low  velocity  wounds  become  in- 
fected, and  only  twelve  per  cent,  of  the  high  velocity.  He 
gives  one  case  as  a  sample;  this  was  one  of  attempted  suicide. 
The  bullet  entered  the  third  interspace  one-half  of  an  inch 
to  the  left  of  the  sternum;  the  exit  was  one-half  inch  ex- 
ternal to  inner  border  of  the  scapula.  The  ball  perforated 
the  chest,  lung,  and  probably  the  pericardium.  The  patient 
recovered.  Dr.  Robinson,  in  his  conclusions,  says  that  the 
modern  gunshot  wound  (by  Mauser,  Krag,  Lee,  etc.,  rifles) 
is  generally  aseptic,  and  should  be  treated  on  this  supposi- 
tion. He  claims  that  the  asepsis  is  due  to  the  character  of 
the  bullet  and  to  its  high  velocity.  The  explosive  effect  of 
the  modern  high-velocity  bullet  is  not  so  common  as  gen- 
erally supposed.  The  peculiar  effect  depends  upon  the  kind 
of  tissue  and  the  velocity.  Gunshot  wounds  were  treated 
by  applying  an  occlusive  antiseptic  dressing. 

"  The  thorax  was  injured  in  one  hundred  and  ninety-eight 
cases,  eighty-four  non-penetrating  and  one  hundred  and  thir- 
teen penetrating  wounds.  Of  the  non-penetrating  wounds, 
one  proved  fatal  after  an  operation  for  traumatic  aneurysm, 
and  one  recovered  after  a  ligation  of  the  subclavian  artery. 
Of  the  penetrating  wounds  thirty-six  cases,  or  thirty-one  and 
nine-tenths  per  cent,  of  the  penetrations,  were  fatal.     The  bullet 


I'LATE     XLV. 


X  300. 

Sarcoma,  (Small  Round  Cell). 


X  120. 


Sarcoma,  (Small  Spindle  Cell). 


(Chapter  on  Malignant   Tumors.) 


GUNSHOT,    LACERATED   AND    INCISED   WOUNDS  329 

was  removed  in  one  case  which  ended  fatally,  and  in  six  cases 
which  recovered.  The  seventh  rib  was  resected  in  one  case, 
and  the  axillary  artery  was  tied  in  one  case  with  favorable  re- 
sult. 

"If  the  penetrating  wounds  of  the  thorax  reported  in 
1898  be  added  to  those  just  mentioned,  the  fatal  cases  are 
found  to  constitute  twenty-seven  per  cent,  of  the  aggregate. 
.  The  aggregate  number  of  deaths,  fifty-five,  forms 
twenty-seven  per  cent,  of  the  aggregate  number  of  cases,  one 
hundred  and  ninety-eight."  (Report  of  the  Surgeon-General, 
U.  S.  A.,  June  30,  1900.) 

(For  Symptoms,  Diagnosis,  and  Treatment,  see  Chapter 
on  Lacerated  and  Incised  Wounds  of  the  Lung;  also  Chapter 
on  Foreign  Bodies.) 

BIBLIOGRAPHY 

Mallet,  W.,  Philadelphia  Trans. ,  London,  1743,  XI,  966-968. 

RiGBY,  E.,  Med.  Comment,  London,  1790,  II,  1-5. 

Home,  E.,  Trans.  Soc.  Improv.  of  Chir.  Knowledge,  London,  1800, 

II,  169-173. 

Key,  London  Med.  Gaz.,  1845;  n.  s.,  I,  341-343. 

Campbell,  G.  W.,  Brit.-Am.  Journ.  Med.  and  Phys.  Sc,  Montreal, 

1846-47,  II,  231-234. 
Moore,  E.,  Lancet,  1847,  !>  67-69. 
Beal,  L.  B.,  South.  Med.  and  Surg.  Jour.,  Augusta,  1847,  ^-  ^•> 

III,  202. 

Eve,  South.  Med.  and  Surg.  Jour.,  Augusta,  1848. 

Longmore,  T.,  Lancet,  London,  1855,  II,  437. 

Upshur,  G.  L.,  Virginia  Med.  and  Surg.  Jour.,  Richmond,  1855, 

IV,  467. 

Warren,  J.  M.,  Boston  Med.  and  Surg.  Jour.,  1857,  LV,  420. 
Clapp,  H.  C,  Chicago  Med.  Jour.,  1861,  n.  s.,  IV,  73-81. 
Peters,  D.  C,  Am.  Med.  Times,  New  York,  i860,  I,  327. 
Sinn,  R.,  Med.  Times  and  Gaz.,  London,  1861,  I,  141. 
Burge,  J.  H.  H.,  Med.  and  Surg.  Report.,  Philadelphia,  1862-63, 
IX,  100-102. 


330  THE  SURGERY  OF  THE  LUNGS 

Farnsworth,  p.  J.,  Med.  and  Surg.  Report.,  Philadelphia,  1865, 

XIII,  233. 
RousTAN,  A.,  Bull.  Soc.  d'Anat.,  Paris,  1865,  XL,  323-326. 
FoRMENTS,  F.,  South.   Jour.  Med.   Sc,  New   Orleans,   1866,  I, 

238,  239. 
Johnson,  W.  O.,  Boston  Med.  and  Surg.  Jour.,  1867-68,  LXXVII, 

345- 
Eve,  P.  F.,  Nashville  Jour.  Med.  and  Surg.,  1867,  n.  s.,  II,  225. 

Woodson,  J.  B.,  Kansas  City  Med.  Jour.,  1872,  II,  274. 

Wright,  D.,  Med.  Gaz.,  Calcutta,  1873,  VIII,  44. 

Chaplain,  E.  L.,  Paris,  1874. 

Lewis,  R.  J.,  Philadelphia  Med.  Times,  1874-75,  V,  294. 

Crawford,  M.  H.,  Virginia  Med.  Month.,  Richmond,  1879,  VI, 

48-50. 

Albuerne,  Cron.  Med.  Quir.  de  la  Hahana,  1890,  XVI,  321-323. 

Hanson  and  Coe,  Med.  Rec,  New  York,  1891,  XL,  536. 

Macwatt,  Brit.  Med.  Journal,  London,  1891,  II,  12. 

BiCKLE,  Australas.  Med.  Gaz.,  Sydney,  1891-92,  XI,  159. 

Gonda,  Gyoaszat,  Budapest,  1891,  XXXI,  340. 

Pinquard,  Oklahoma  Med.  Journ.,  Guthrie,  1893,  I,  112-116. 

Wilson,  Fort  Wayne  Med.  Jour.,  1897,  XVII,  191-193. 

Da  Costa,  Ann.  Surg.,  1898,  XXVII,  97-100. 

LACERATED  AND  INCISED  WOUNDS.— Under  this  caption 
are  considered  all  those  varieties  of  lung  injury  which  have  not 
been  treated  elsewhere.  This  is  in  accordance  with  the  classi- 
fication commonly  employed. 

Historical  (1770-1903). — A  fellow-officer  wounded  with 
General  Wolfe  at  Quebec,  1759,  is  said  to  have  recovered  after 
the  removal  of  a  large  portion  of  the  injured  lung.  (Gould  and 
Pyles's  Anomalies  and  Curiosities  of  Medicine,  Philadelphia, 
1 897. )  As  early  as  i  yyy,  Pew  gave  an  account  of  a  most  won- 
derful recovery  after  a  wound  through  the  lung.  Ruddock 
mentions  cases  of  penetrating  wounds  of  both  lungs  with  re- 
covery. A  paper  in  the  London  Medical  Times  (1844)  gives 
the  particulars  of  a  penetrating  wound  of  the  right  lung  with 


GUNSHOT,    LACERATED    AND    INCISED    WOUNDS  33 1 

emphysema.  Sewell  (1849)  reported  a  case  of  transfixion  of 
the  chest  of  a  youth  eighteen  years  old,  who  accidentally  fell  on 
a  scythe  blade,  the  point  passing  under  the  right  axilla,  between 
the  third  and  fourth  ribs  straight  through  the  chest.  There 
was  no  haemoptysis,  and  the  patient  soon  recovered. 

Core  (1859)  reported  a  case  of  laceration  of  the  lung  and 
collapse  of  the  organ  without  fracture  of  the  ribs.  In  the 
Sydenham  Society  Transactions  (i860)  appears  Casper's  re- 
port (pp.  1-165)  of  two  cases  of  wound  of  the  lung ;  in  one  case 
a  carriage  pole  and  in  the  other  the  end  of  a  mast  passed  through 
the  lung.  Both  cases  recovered.  Finnell  (1861)  had  a  caseof 
a  man  struck  by  an  iron  bar.  It  penetrated  the  thorax  three 
inches  into  the  floor,  having  entered  posteriorly  between  the 
ninth  and  tenth  ribs  of  the  left  side,  coming  out  anteriorly  be- 
tween the  fifth  and  sixth  ribs.  There  was  but  slight  constitu- 
tional disturbance,  the  man  soon  recovered. 

Chicon  treated  a  wound  of  the  lung,  where  there  was  much 
purulent  matter,  by  thoracentesis.  Adams  (1867)  reported  a 
case  of  penetrating  wound  of  the  right  lung  with  external  em- 
physema. Longmore  ( 1871 )  gives  a  case  where  a  lance  trans- 
fixed the  right  side  of  the  chest  and  lung;  the  soldier  recovered. 
Rivington  (1871)  reported  an  interesting  case  of  an  incised 
wound  of  the  shoulder  and  chest;  the  lung  was  penetrated. 
There  was  paralysis  agitans,  apparently  hereditary;  recovery 
ensued.  Pozzi  (1873)  reported  a  complicated  case  of  wound 
of  the  lung;  there  was  no  haemoptysis,  but  ossiform  concretions 
formed,  simulating  fracture  of  the  ribs.  There  was  also  sup- 
puration of  the  pericardium,  resulting  in  death.  De  Morgan 
( 1874)  reported  a  case  of  penetrating  wound  of  the  chest  with 
an  iron  rail,  with  laceration  of  the  lung  and  death. 

Richards  (1875)  reported  a  wound  of  the  lung  with  recov- 
ery, and  (1880)  an  equally  interesting  case  of  recovery  from  a 
penetrating  wound  of  the  thorax  with  immediate  pneumocele, 
requiring  excision  of  a  portion  of  the  lung.  Brown  reports  a 
case  of  a  boy,  who,  while  running  to  a  fire,  struck  the  point  of 


332  THE  SURGERY  OF  THE  LUNGS 

a  carriage  shaft,  which  passed  through  the  left  chest  below  the 
nipple.  There  was  no  haemorrhage;  the  boy  recovered.  In- 
glott  (1890)  reported  a  case  of  wound  of  the  right  lung,  fol- 
lowed by  immediate  recovery. 

Brokaw  reported  the  case  of  a  shipping-clerk,  who  received 
a  thoracic  wound,  extending  from  the  third  rib  to  within  one 
inch  of  the  navel,  thirteen  and  one-half  inches  long,  completely 
severing  all  the  muscular  and  cartilaginous  structures.  In 
addition,  there  was  a  terrible  abdominal  wound,  causing  almost 
complete  intestinal  evisceration.  The  lung  partially  collapsed. 
The  cartilages  were  ligated  with  heavy  silk,  and  haemorrhage 
checked  by  ligature  and  by  packing  gauze  in  the  interchondral 
spaces.  The  patient  was  discharged  in  a  little  over  a  month,  the 
only  evil  result  remaining  being  a  small  ventral  hernia. 

Sadler  (1891)  reported  a  case  of  stab  wound  of  the  lung. 
Montel  ( 1891 )  reported  a  lung  wound  and  Reading  ( 1891 )  re- 
ported a  case  of  perforating  wound  of  the  right  lung  wit-h  re- 
covery. Hodenpyl  (1893)  reported  a  perforating  w^ound  and 
Alexander  (1893)  had  a  case  of  a  stab  wound  of  the  lung. 
Lopez  (1894)  reported  a  recovery  in  a  case  of  penetrating 
w^ound  caused  by  a  sword. 

Pyle  (1894)  reported  a  case  of  a  boy  who  had  been  run  over 
by  a  hose-cart.  There  were  no  signs  of  external  injury  and  no 
fracture  of  the  ribs.  There  was  marked  emphysema ;  the  neck 
and  side  of  face  were  greatly  swollen  by  the  extravasated  air ; 
the  tissues  of  arm  were  also  infiltrated  with  air ;  consciousness 
was  never  lost.  On  the  eighth  day,  the  temperature  was  nor- 
mal. The  boy  left  the  hospital  apparently  well,  without  evi- 
dence of  pulmonary  embarrassment.  He  developed  diaphrag- 
matic breathing  which  seemed  fully  sufficient. 

In  the  Annals  of  Universal  Medical  Science  (1872),  there 
appeared  an  extraordinary  case  of  a  boy,  fifteen  years  of  age, 
who,  by  falling  into  the  machinery  of  an  elevator,  was  severely 
injured  about  the  chest;  there  were  six  extensive  lacerations, 
five  through  the  skin,  about  six  inches  long,  and  one  through 


Plate  XLVI. 


X  110. 
Sarcoma,    (Giant  Cell). 


X  70. 

Carcinoma,  (Epithelial). 


(Chapter  on  Malignant   Tumors.) 


GUNSHOT,    LACERATED   AND   INCISED    WOUNDS  333 

the  chest  ab'out  eight  inches  long.  The  third,  fourth,  fifth  and 
sixth  ribs  were  fractured  and  torn  apart,  and  about  an  inch  of 
the  fourth  rib  was  lost.  Several  jagged  fragments  were  re- 
moved. A  portion  of  the  pleura,  two  by  four  inches,  had  been 
torn  away,  exposing  the  pericardium  and  the  left  lung,  showing 
the  former  to  have  been  penetrated,  and  the  latter  torn.  The 
lung  collapsed  completely,  and  for  three  or  four  months  no  air 
seemed  to  enter  it,  but  respiration  gradually  returned.  The 
patient  finally  recovered,  without  lateral  curvature. 

There  is  an  Indian  report  of  penetrating  wound  of  the  lung 
by  Roy  (1895).  Gazotti  (1897)  also  reported  his  operation 
for  a  traumatic  injury  of  the  lung.  Tunnin  (1897-98)  wrote 
on  surgical  intervention  in  grave  injuries  of  the  lung,  and  also 
on  lung  surgery  in  general.  Hadra  (1898)  indorses  pneu- 
monotomy,  as  does  Doyen  (1898)  in  an  article  on  surgery  of 
the  lungs.  Tait  (1898)  uses  the  word  "  pneumonotomy  "  in 
reporting  a  case. 

In  1894  the  author  had  a  patient,  who,  in  1887  had  been 
stabbed  with  a  knife.  The  wound,  three  inches  long,  extended 
through  the  intercostal  space.  Six  ribs  were  resected  and  the 
lung  was  found  atrophied  to  the  size  of  a  man's  fist.  No 
normal  lung  tissue  remained.  Patient  was  in  excellent  condi- 
tion April  I,  1903. 

In  1869  G.  R.  Ricketts  was  called  to  treat  a  man  who  had 
been  thrown  on  a  circular  saw.  It  was  found  that  all  the  ribs 
on  the  right  side  had  been  divided,  within  two  inches  of  the 
spinal  column.  The  scapula  was  divided  also.  The  teeth  of 
the  saw  penetrated  the  lung  itself,  severing  the  second  branch 
of  the  right  bronchus.  The  wound  was  cleaned  of  debris  (part 
of  the  man's  shirt  had  been  forced  into  the  thoracic  cavity) ,  and 
closed  with  sixty-nine  sutures.  In  spite  of  infection,  which 
occurred,  the  man  recovered.  He  is  alive  and  well  thirty- four 
years  after  the  accident. 

Only  penetrating  wounds  and  injuries  of  the  chest  wall  in- 
volving the  continuity  of  the  lung  are  herein  considered.     All 


334  THE    SURGERY    OF   THE   LUNGS 

other  wounds  of  the  chest  wall  have  been  disregarded.  Re- 
search work  to  determine  what  can,  and  what  cannot  be  done 
with  the  lung,  has  been  slight  in  comparison  with  the  work  done 
on  other  organs  of  the  body.  However,  enough  has  been  ac- 
complished to  establish  many  important  facts.  The  surgery 
involved  in  this  class  of  cases  is,  perhaps,  more  interesting,  al- 
though less  frequent,  than  tuberculous  abcesses.  More  hope, 
however,  can  be  given.  In  one,  a  chronic  condition,  which  has 
become  desperate  and  hopeless,  is  encountered,  while  in  the 
other,  a  healthy  subject  is  usually  the  victim. 

Of  rupture,  gunshot  wounds,  and  injury  to  lung  from  lacer- 
ation, haemorrhage  is  one  of  the  most  important  symptoms.  It 
may  be  rapid  or  slow,  primary  or  secondary,  or  it  may  be  latent 
from  any  of  the  thoracic  or  pulmonary  vessels.  If  haemorrhage 
be  latent,  it  may  in  most  cases  be  from  the  thoracic  or  pulmo- 
nary vessels.  If  the  haemorrhage  be  external,  the  intercostal  or 
internal  mammary,  or  both,  are  injured.  The  signs  of  lung 
bleeding  are  dyspnoea,  rapid  and  difficult  breathing,  am- 
phoric sound,  metallic  tinkling,  faintness,  pale,  livid  lips, 
pain,  cough,  cold  sweat,  vomiting,  anxiety,  oppressed  circu- 
lation, engorgement  of  lung,  dusky  countenance,  and  hard 
pulse. 

Air  in  wound  or  the  expectoration  of  froth  may  confuse 
diagnosis.  Blood  may  escape  from  the  lobe  into  the  pleural 
cavity,  and  thence  through  the  chest  wound,  bronchus,  or 
mouth,  into  the  pericardial  or  mediastinal  space,  the  oesophagus, 
or  into  the  peritoneal  cavity.  Each  or  all  of  these  conditions 
may  exist  at  one  and  the  same  time. 

When  the  haemorrhage  is  intrathoracic  there  is  frequently 
haemoptysis.  This  may  be  distinguished  by  the  presence  of 
rales  in  the  bronchi  of  the  affected  lung,  history  of  injury,  etc. 
Ha^mopericardium  causes  an  increase  in  the  area  of  cardiac  dul- 
ness  and  interferes  with  the  heart's  action.  Hcemomediastinum 
produces  physical  signs  similar  to  those  of  abscess.  If  hcnemo- 
thorax  or  pneumothorax  be  present  without  hcemoptysis  the 


GUNSHOT,    LACERATED   AND   INCISED    WOUNDS  335 

lung  is  intact,  and,  usually,  the  bleeding  parietal.  Hsemoperi- 
cardium  is  not  always  proof  of  injury  to  the  heart  itself.  If 
there  is  haemoptysis,  there  are  more  rales  in  the  injured  lung 
than  in  the  sound  one. 

One  of  the  curious  facts  noticed  by  ancient  writers  was  the 
amelioration  of  the  symptoms  caused  by  thoracic  wounds  after 
haemorrhage  from  other  locations,  and  naturally  in  the  treat- 
ment of  such  injuries,  this  circumstance  was  used  in  advocacy 
of  depletion.      (Gould  and  Pyle,  1897.) 

Haemoptysis  may  be  due  to  a  blow  upon  a  pathologic  lung 
where  cysts,  abscess,  tumors,  etc.,  are  present,  and  may,  there- 
fore, be  confusing.  It  may  also  come  from  the  trachea,  nose,  or 
mouth.  The  patient  may  not  spit  or  cough  blood  in  severe  lac- 
eration of  the  lung,  especially,  in  gunshot  or  penetrating 
wounds,  other  than  that  from  a  knife  or  sharp-pointed  instru- 
ment. Contusion  may  cause  emphysema,  and  it  is  always  more 
or  less  present  in  the  lung  to  which  it  is  confined,  unless  the 
parietal  pleura  is  lacerated,  in  which  case  the  emphysema  may 
extend  to  the  chest  wall  and  become  local  or  general.  Sub- 
cutaneous emphysema  rarely  occurs  after  a  rupture  of  the  lung, 
unless  there  is  pneumothorax.  Pneumothorax,  haemothorax, 
pleurisy  with  or  without  effusion,  rupture  of  lung  or  diaphragm, 
may  appear  alone  or  together  soon  after  injury.  Emphysema 
and  pneumothorax  are  of  little  importance,  especially  the  latter. 
Percussion  is  of  little  or  any  value  if  air  is  in  the  pleural  cavity, 
or  a  large  bronchus  be  severed,  in  which  case,  the  lobe  which  it 
supplies  would  be  retracted  upon  itself. 

Senn  claims  that  a  rise  in  temperature  during  the  first  forty- 
eight  hours  is  no  indication  of  the  existence  of  sepsis,  as  with 
few  exceptions,  it  indicates  a  febrile  disturbance,  caused  by  the 
absorption  of  fibrin  ferment,  the  so-called  "  fermentation 
fever."  He  also  claims  "  That  rest  in  the  recumbent  position, 
with  the  chest  slightly  elevated,  is  essential  in  aiding  spontane- 
ous arrest  of  haemorrhage,  and  in  preventing  complications." 
(Journal   American    Medical    Association,    July    9,     1898.) 


336  THE   SURGERY   OF  THE   LUNGS 

Others  claim  that  in  cases  where  there  is  fluid  in  the  pleural 
cavity  a  rise  in  temperature  indicates  infection. 

When  the  laceration  of  the  lung  is  extensive,  there  is  im- 
mediate haemorrhage  into  the  bronchi,  and  haemoptysis,  imme- 
diate and  copious.  There  is  severe  shock  and  collapse,  thready 
pulse,  labored  and  irregular  breathing,  and  subnormal  temper- 
ature. Physical  examination  reveals  evidence  of  pneumotho- 
rax. The  first  twenty-four  hours  are  full  of  danger.  The 
patient  may  die  of  shock,  loss  of  blood,  or  by  drowning  in  his 
own  blood.  After  the  shock  has  passed  away,  the  case  is  that 
of  pneumothorax  with  a  tendency  to  secondary  inflammation 
of  the  lung  and  pleura.  If  the  injury  be  kept  free  from  infec- 
tion, and,  if  there  is  no  large  haematoma,  recovery  will  take 
place  in  a  few  days. 

The  prognosis  depends  on  the  reaction  of  the  vital  forces  of 
the  patient.  But  it  must  be  remembered  that  where  there  is  a 
large  external  wound,  there  is  danger  from  external  haemor- 
rhage and  sepsis,  as  well  as  from  internal  haemorrhage  and  sep- 
sis. In  such  a  case  there  may  be  traumatopnoea  instead  of  em- 
physema. 

When  the  lung  has  been  injured,  whether  the  wound  be  a 
simple  rupture  or  laceration  of  the  lung,  there  is  often  injury  to 
the  mediastinal  and  thoracic  vessels.  In  such  cases,  if  the 
great  vessels  are  injured,  immediate  and  fatal  haemorrhage  re- 
sults. There  may  be  later  complications,  such  as  aneurysm  and 
mediastinal  abscess. 

In  case  of  injury  to  the  thoracic  duct,  it  is  said  to  heal  if 
the  duct  is  not  completely  divided.  Thorough  examination 
should  be  made  of  the  mediastinal  space.  If  clots  be  present, 
they  must  be  removed,  incising  the  chest  wall  if  necessary. 

Treatment — Venesection  is  especially  desirable  when  as- 
phyxia is  present ;  it  will  relieve  dyspnoea,  as  shown  by  actual 
experiment.  Although  it  has  been  stated  that  about  one  in  ten 
cases  of  lung  injuries  should  be  venesected,  none  has  as  yet 
been  reported  treated  in  this  way. 


GUNSHOT,    LACERATED    AND    INCISED   WOUNDS  337 

Dissect  bronchus  and  ligate,  using  small  needle  with  kan- 
garoo tendon.  Dissect  out  all  bleeding  vessels,  ligate  and  pack 
with  gauze.  Adhesions  are  greater  in  the  aged.  Take  tempera- 
ture before  and  after  in  axilla.  Catgut,  unless  chromicised, 
should  not  be  used  in  lung  surgery.  Air  must  be  excluded 
from  chest,  which  necessitates  complete  closure  of  bronchi, 
which  is  difficult  with  ligature.     Palpate  lung  with  the  finger. 

Small  balls  from  small-bore  guns  are  more  likely  to  lodge  in 
the  lungs.  Such  cases  are  more  favorable,  as  the  bullets  are 
more  likely  to  become  encysted.  Mortality  is  higher  when  bul- 
lets pass  through  the  chest  from  side  to  side,  or  at  the  base  of  a 
lobe.  But  the  nearer  the  diaphragm  the  w^ound  may  be,  the 
more  favorably  is  it  situated  for  drainage,  and  the  more  favor- 
able is  the  prognosis. 

The  care  of  wounds  of  the  lung,  whether  gunshot,  incised, 
or  lacerated,  has  been  the  subject  of  great  controversy.  Dr. 
Antona  recommends  in  rupture  of  the  lung  to  provoke  cough- 
ing, compressing  the  sound  lung  at  the  same  time,  which  causes 
the  diseased  lung  to  bulge  out  through  the  wound,  and  prevents 
pneumothorax.  (Surgery  of  the  Lung,  Journal  American 
Medical  Association,  January  i6,  1898,  p.  169,  col.  xxx.) 

Do  not  move  or  examine  the  patient ;  never  place  the  patient 
erect,  nor  percuss,  or  cause  deep  inspiration,  or  expiration.  Pre- 
vent coughing  by  giving  codeia,  or  morphine  if  necessary. 
Watch  color  of  skin,  expression  of  face,  and  pulse.  Determine, 
if  possible  before  operating,  whether  or  not  the  diaphragm  is 
injured,  as  it  may  be  necessary  to  open  both  the  thoracic  and 
abdominal  cavities. 

Gunshot  wounds,  sometimes  simulate  those  from  a  knife. 
The  mortality  is  about  sixty  per  cent,  on  the  field  of  battle. 

Dupuytren,  Pirigoff,  Gross,  Erichsen,  and  others  used  the 
probe.  Daunne,  Legonest  and  the  more  modern  writers  do  not 
use  the  probe  or  finger.  Dessault,  Richter  and  B.  Bell  raised 
serious  objections,  and  Foulmart  opposed  sounding  in  all  cases 
of  penetrating  wounds.     The  external  wound  should  never  be 


338  THE  SURGERY  OF  THE  LUNGS 

hermetically  sealed,  as  suggested  by  Howard.  Deunne  says, 
"Examine  the  chest,"  old  masters  say  not  to  do  so.  This  is  a 
matter  of  judgment  on  the  part  of  the  surgeon. 

Wound  of  the  diaphragm  should  not,  however,  prevent  the 
adoption  of  surgical  measures.  {Journal  American  Medical 
Association,  Vol.  XXX,  p.  140,  Vol.  XXIX,  p.  1207.) 

The  treatment  of  haemorrhage  is  of  great  importance  in  this 
connection.  To  stop  haemorrhage  from  the  great  vessels,  all 
that  can  be  done  is  to  keep  the  patient  absolutely  quiet,  using 
morphine  liberally,  and  possibly  gelatine  in  one  per  cent,  solu- 
tion hypodermically  or  in  the  rectum. 

For  haemorrhage  from  the  lung  the  expectant  course  is  ad- 
vocated by  most  surgeons,  although  some  say  to  cut  down  upon 
and  pack  the  visceral  wound.  If  nothing  is  done,  the  lung  will 
bleed  until  it  has  completely  retracted ;  that  is,  if  there  be  no  ad- 
hesions, and  if  the  pleura  be  not  full  of  blood. 

Some  writers  favor  "  splinting  "  the  lung  by  the  injection 
of  air  into  the  pleura.  One  prominent  writer  ixiakes  the  as- 
tounding assertion  that  "  clotting  "  seems  not  to  occur  in  the 
pleura  of  man.  But  experiments  and  observation  prove  that 
this  statement  is  untrue.  The  blood  does  clot  in  the  pleura  as 
in  any  other  part  of  the  body. 

In  case  of  laceration  of  the  lung,  where  there  is  a  large  ex- 
ternal wound,  local  therapeusis  is  required  to  prevent  external 
haemorrhage  and  sepsis.  The  wound  of  the  thoracic  walls 
should  be  treated  as  an  ordinary  surgical  wound.  Endeavor 
to  obtain  asepsis  by  removing  foreign  bodies  and  by  copious 
irrigation  with  sterile  solutions.  Pressure  or  ligature,  will  se- 
cure haemostasis.  Do  not  allow  any  of  the  solution  that  is 
used  to  get  into  the  pleural  cavity.  Only  simple  aseptic,  and 
not  antiseptic,  solutions  should  be  used;  so  that  if  any  part  of 
the  solution  does  get  into  the  pleural  cavity,  it  will  do  as  little 
harm  as  possible. 

Bandaging  with  adhesive  plaster,  muslin,  or  plaster  of  Paris, 
in  an  attempt  at  fixation  of  the  chest  to  place  the  lung  at  rest 


Plate  XLVII. 


^ 


Ww^- 


:><- 


X  1000. 

Bacillus  Anthracis,    (Spores). 


A    • 


\ 


/  't- 


\    \ 


X  1(10(1. 
Bacillus   Amrogexks  Capsulatus. 


(Chapter  on  Bacilli.) 


GUNSHOT,   LACERATED  AND   INCISED   WOUNDS  339 

is  useless,  for  it  cannot  be  clone.  The  lung  when  inflated, 
presses  upon  the  chest  wall  equally  in  all  directions  so  that  if 
the  bony  chest  could  be  prevented  from  expanding  in  any  of 
its  diameters,  the  diaphragm  would  give  compensation.  The 
lung  cannot  be  put  at  perfect  ease  even  when  the  chest  wall  is 
open,  for  even  then  there  is  slight  motion. 

(See  chapters  on  Foreign  Bodies,  Surgery  of  the  Lungs, 
and  Gunshot  Wounds.) 


BIBLIOGRAPHY 

Pew,  R.,  Med.  and  Phil.  Comm.,  London,  1777,  V,  188-190. 
Bell,  R.,  Med.  Comm.,  London,  1787,  decade  2, 1,  349-352. 
Ruddock,  Prov.   Med.   and  Surg.  Jour.,  London,  1842.    Med. 

Times,  London,  1844,  X,  551. 
Sewell,  Am.  Jour.  Med.  Sc,  Philadelphia,  1849. 
Skinner,  J.  A.,  West.  Lancet,  San  Francisco,  1852,  XIII,  468-470. 
Ferrari,  Raccog.  Medico  di  Fan.,  1^855. 
Core,  W.  R.,  Dublin  Med.  Press.  1859,  XLI,  194. 
Finnell,  Med.  Times,  New  York,  1861,  II,  304. 
HoYLAND,  London  Med.  Record,  1863,  II,  241. 
Chicon,  Gaz.  d.  Hdp.,  Paris,  1865,  XXXVIII,  394. 
Adams,  J.,  Lancet,  London,  1867,  II,  665. 
Longmore,  Lancet,  London,  1871,  I,  78. 
RiviNGTON,  Med.  Press  and  Circ,  London,  1871,  XI,  3. 
Pozzi,  S.,  Bull.  Soc.  d'Anat.  de  Paris,  1873,  XLVIII,  749-753. 
De  Morgan,  C.,  Lancet,  London,  1874,  I,  90. 
Richards,  V.,  Indian  Med.  Gaz.,  Calcutta,  1875,  X»  213. 
Brown,  Trans.  Med.  Soc.  Pennsylvania,  1877,  pt.  2,  730. 
Richards,  Indian  Med.  Gaz.,  Calcutta,  1880,  XV,  213. 
Inglott,  Brit.  Med.  Journal,  London,  1890,  I,  75. 
Brokaw,  St.  Louis  Courier  of  Med.,  etc.,  1890. 
Sadlier,  New  York  Med.  Jour.,  1891,  LIV,  266. 
Montel,  Gazz.  d.  Osp.,  Napoli,  1891,  XII,  592. 
Reading,  Med.  News,  Philadelphia,  1892,  LX,  156. 


340  THE  SURGERY  OF  THE  LUNGS 

HoDENP\x,  Med.  Rec,  New  York,  1893,  XLIII,  535. 

Alexander,  Jour.  Med.  and  Surg.,  1893,  LXXIII,  247. 

Lopez,  Encyclopedia,  Barcelona,  1894,  VII,  37-46. 

Pyle,  Med.  News,  Philadelphia,  Feb.,  1894. 

Roy,  Indian  Lamet,  Calcutta,  1895,  VI,  305. 

RiCKETTS,  B.  M.,  Cincinnati  Lancet  and  Clinic,  1896,  p.  237. 

G.\Z0TTi,  Gazz.  d.  Osp.,  Milano,  1897,  XVIII,  1063. 

Fixkelstein,  B.  K.,  Stab  wounds  of  Thorax. 

Bertolucci,  p.,  Corriere  San  Milano,  1900. 

Le  Boutillier,  W.  G.,  Annals  of  surger}%  Philadelphia,  1902, 

XXXV,  553-573. 

Cerne,  Normandie  Med.,  Rouen,  1902,  XVIII,  200. 


CHAPTER    VII 
FOREIGN    BODIES 

Foreign  bodies  in  the  lung  or  bronchi  may  be  removed  by- 
coughing,  and  may  escape  through  the  chest  wall  into  the 
trachea,  oesophagus,  or  through  the  diaphragm,  and  from  the 
subcutaneous  tissue  at  almost  any  point  upon  the  body.  Small 
foreign  bodies,  such  as  bird-shot,  may  become  encysted  in  the 
lung  and  remain  harmless,  while  others  may  gravitate,  from 
their  excessive  weight,  through  the  entire  lobe  and  drop  into  the 
pleural  cavity,  to  cause  subsequent  serious  trouble.  Foreign 
bodies  may  enter  the  chest  cavity,  and  only  the  chest  wall  be 
injured.  Their  course  depends  upon  the  angle  described  by 
the  missile. 

Experiments  with  the  x  ray  show  that  the  position  of  a 
foreign  body  in  the  lung,  when  expanded,  is  changed  when  the 
chest  is  opened  and  the  lung  contracts.  The  foreign  body  may 
not  be  in  the  bronchus  but  in  the  lung  tissue. 

Historical  (1671-1903). — Buchtfield  (1671-72)  was  among 
the  earliest  writers  who  published  anything  with  reference  to 
foreign  bodies  in  the  lungs.  Tillingius  (1688)  refers  to  cal- 
culi having  been  expelled  from  the  lungs.  Kirby  (1700)  wrote 
on  the  same  subject  and  Arnot  ( 1742)  published  cases  of  bone 
having  been  removed  by  coughing. 

De  Carendeffez  (1803)  gave  an  analytical  description  of 
certain  stony  concretions  coughed  up  from  the  lungs ;  Valentine 
(1807)  reported  his  observations  on  stony  concretions  expec- 
torated by  a  phthisical  patient;  Gilroy  (1831)  reported  a  case 
of  pulmonary  abscess  caused  by  the  lodgement  of  a  chicken- 

341 


342  THE   SURGERY   OF   THE   LUNGS 

bone  in  one  of  the  bronchi.  Graham-Craig  (1834)  reported  a 
case  of  the  deposit  of  charcoal  in  the  lungs  of  a  miner  {anthra- 
cosis).  Brigham  ( 1838)  published  a  case  in  which  a  brass  nail 
was  found  in  the  lung;  Burford  (1838)  reported  cases  of  con- 
cretions in  the  lungs.  Judd  (1838)  reported  on  calcareous  and 
bone-like  concretions,  and  Barker  (1842)  reported  a  case  of 
foreign  body  in  the  lung. 

Maikeller  ( 1846)  reported  a  case  of  black  phthisis,  or  ulcer- 
ation, induced  by  carbonaceous  accumulations  in  the  lungs  of 
coal  miners.  There  are  numerous  reports  of  cases  of  bones, 
and  various  kinds  of  foreign  bodies  having  been  expelled  from 
the  lungs,  one  of  which  is  that  of  Struthers  (1852),  where  a 
foreign  body  was  in  the  bronchus  for  four  and  one-half  years. 
The  case  terminated  fatally  by  gangrene. 

Wales  ( 1854)  reported  a  case  of  bronchitis  occurring  in  the 
person  of  a  muslin  gassurger  in  whom  the  expectoration  was  so 
charged  with  charcoal  as  to  resemble  that  of  pneumonia. 

Hamilton  (1854)  contributes  to  the  literature  of  the  expec- 
toration of  calcareous  bodies.  The  calcareous  bodies  are 
formed  in  the  pulmonary  veins  and  are  about  the  size  of  bird- 
shot  and  yellowish-white  in  color.  They  are  composed  of  car- 
bonate or  phosphate  of  lime. 

Emison  ( 1856)  had  a  case  in  which  a  bullet  was  expelled  by 
coughing,  two  weeks  after  it  had  entered  the  thorax.  Leach 
gave  a  case  in  which  a  bullet  was  impacted  in  the  chest  for 
forty-two  years.  Hamilton  ( 1858)  reported  a  case  in  which  he 
removed  a  knife  from  the  left  pleural  cavity  by  the  exsection  of 
the  sixth  rib,  and  the  introduction  of  the  hand.  Bristowe 
(1857)  reported  a  case  of  a  foreign  body  in  the  lung.  Evan 
(1861)  gave  an  account  of  a  case  of  abscess  of  the  lung  from 
the  presence  of  a  foreign  body,  which  was  evacuated  through 
the  bronchial  tubes  and  through  the  thoracic  walls ;  the  patient 
recovered. 

There  seems  to  be  no  way  by  which  small  foreign  bodies, 
such  as  coal  deposits,  can  be  removed  from  the  pulmonary 


Plate  XLVIII. 


Bacillus  Friedlander_,   (Acute  Croupous  Pneumonia), 
(Copied  from  another  publication.) 


X  Co. 

Pneumonia^  (Human  Lung), 


<Chapter  on  Bacilli.) 


FOREIGN  BODIES  343 

tract.  They  are,  no  doubt,  a  prominent  factor  in  the  causation 
of  bronchitis  and  tuberculosis,  especially. 

Greenhow  (1864)  reported  on  specimens  of  coal  miners' 
black  lungs.  Bruce  (1866-67)  reported  a  case  of  necrosis  of 
the  rib,  encapsuled  for  three  years  in  the  lung.  Snyder  speaks 
of  a  piece  of  a  knife  blade  which  was  lodged  in  the  chest  twelve 
years  and  finally  coughed  up.  J.  P.  Logan  (1872)  had  a  case 
of  pneumonia  in  a  child,  following  an  abscess  caused  by  a  can- 
taloupe seed  in  the  lung.  Day  ( 1 873 )  gives  a  case  of  the  pas- 
sage of  a  foreign  body  through  the  right  lung  with  recovery. 

Johnston  of  Baltimore  (1876),  in  the  presence  of  Sir  Mo- 
rell  Mackenzie,  removed  a  toy  locomotive  from  the  subglottic 
cavity  by  tracheotomy  and  thyrectomy.  G.  R.  Ricketts  ( 1873) 
had  a  case  of  a  girl,  six  years  old,  who  had  a  pebble  in  the  right 
lung;  it  was  never  expelled.  The  child  died  two  years  later 
from  tuberculosis. 

On  page  372,  Volume  II,  Gross's  "Surgery,"  is  found  the 
case  of  Arnot,  where  recovery  ensued  after  the  removal  of  a 
piece  of  iron  hoop  which  had  remained  in  the  lung  fourteen 
years.  On  page  371  of  the  same  volume  is  found  a  case,  men- 
tioned by  Bayer,  of  a  man  wounded  at  the  battle  of  Novi  who 
lived  seven  years  with  a  ball  in  the  base  of  the  left  lung.  Guil- 
lon's  case  of  a  piece  of  fence  nail  remaining  eighteen  years  in  the 
lung,  is  given  on  page  372  of  the  same  volume. 

Knox  (1885)  also  reported  a  case  of  a  foreign  body  in  the 
lung,  and  Bloxam  (1886)  mentioned  a  case  resulting  from  the 
swallowing  of  a  fish-bone. 

Lapeyre  reported  a  case  of  an  elderly  gentleman  who  was 
suddenly  slapped  on  the  back  while  smoking  a  cigarette.  This 
caused  him  to  give  a  start,  and  the  very  deep  inspiration  which 
he  naturally  took  caused  the  cigarette  to  be  drawn  into  the  right 
bronchus.  Here  it  remained  two  months  without  revealing  its 
presence  in  any  way.  Then  circumscribed  pneumonia  and  car- 
diac dropsy  set  in,  and  two  months  afterward  the  cigarette  was 
expelled  during  a  violent  fit  of  coughing. 


344  THE  SURGERY  OF  THE  LUNGS 

Dr.  N.  K.  Moxley  personally  communicated  to  the  author 
an  account  of  a  case  that  came  under  his  care  in  which  the  silver 
tip  of  a  spray  tube  was  coughed  up  after  having  been  forty  days 
in  the  bronchus. 

Kocher  (1890)  published  his  method  of  extracting  foreign 
bodies  from  the  lungs.  Epler  (1891)  reported  a  case  of  for- 
eign body  in  the  lung. 

Braun's  work  on  treating  cases  of  foreign  bodies  in  the 
lungs  appeared  in  1891.  Perez  Valdes  the  same  year  had  a 
paper  on  foreign  bodies  in  the  lungs  and  Middleton  ( 1892)  re- 
ported two  cases.     Smyth  (1892)  reported  a  similar  case. 

Rehtenbacher  (1891)  published  his  method  of  treatment 
and  Schild  (1893)  wrote  a  paper  on  the  same  subject.  Overall 
reported  the  presence  of  a  silver  tube  in  the  lung  for  twenty 
years. 

During  the  years  of  1897-98,  Farmer,  Hogner,  Yarbat,  and 
Aynoly  reported  cases  of  foreign  bodies  in  the  lung ;  usually  re- 
covery followed  treatment.  Smith  ( 1899)  had  a  case  of  a  for- 
eign body  in  the  lung,  simulating  tuberculosis.  Winter  and 
Coon  have  each  reported  cases,  and  Moffatt  had  a  case  of  cart- 
ridge in  the  right  bronchus. 

Weist's  record  of  one  thousand  cases  of  foreign  body  in  the 
lung  are  very  interesting;  of  one  hundred  and  seventy-seven 
cases,  sixty-six  were  expelled  with  recovery,  twenty-six  died 
without  operation,  and  eighty-five  underwent  tracheotomy.  Of 
the  latter,  sixty-six  recovered,  and  nineteen  died. 

In  one  hundred  and  nine  cases  due  to  watermelon  seed,  sev- 
enty got  well  without  operation,  three  died  without  it,  thirty- 
four  had  tracheotomy  performed,  of  which  twenty-six  recov- 
ered, and  eight  died.  Coffee  beans  caused  fifty-nine  cases, 
most  of  which  recovered  without  operation.  In  three  hundred 
and  seventy-one  miscellaneous  cases,  two  hundred  and  sixty- 
three  had  no  operation,  and  one  hundred  and  nine  recovered; 
one  hundred  and  eight  had  tracheotomy,  and  seventy-seven 
recovered.     Of  one  thousand   other  cases,   ninety-three  had 


FOREIGN    BODIES  345 

tracheotomy  performed,  but  foreign  bodies  could  not  be  found 
in  seventy-three  of  them.  In  five  of  these,  the  body  was  ex- 
pelled through  the  mouth  after  the  wound  had  closed.  In 
sixty-three  of  the  one  thousand  cases,  forceps,  hooks,  etc.,  were 
used  successfully  to  remove  the  body.  The  total  number  of 
operations  was  three  hundred  and  thirty-eight,  of  which  two 
hundred  and  forty-five  recovered,  and  ninety-three  died.  The 
voices  of  ten  were  lost,  and  impaired  in  thirty-eight. 

Where  laryngotomy  was  performed,  out  of  thirty-six  cases, 
thirty  recovered,  and  six  died.  Under  laryngo-tracheotomy, 
out  of  twenty-six  cases,  nineteen  recovered,  and  seven  died. 
Under  tracheotomy  alone,  of  two  hundred  and  seventy-six 
cases,  one  hundred  and  ninety-six  recovered,  and  eighty  died. 

Durham  compiled  a  list  of  five  hundred  and  fifty-four  cases. 
Of  these  two  hundred  and  eighty-three  were  operated  upon, 
and  24.8  per  cent.  died.  Two  hundred  and  seventy-one  were 
not  operated,  and  42.5  per  cent.  died.  There  were  one  hundred 
and  sixty-seven  tracheotomies,  of  which  thirty-seven,  or  22.15 
per  cent.,  died.  It  was  his  opinion  that  the  greater  number  of 
fatalities  was  not  due  to  the  operation,  but  to  delay  in  its  per- 
formance, or  deficiency  in  the  after  treatment. 

Gross  tabulated  one  hundred  and  two  cases.  All  of  these 
were  operated  upon,  with  a  mortality  of  14. 11  per  cent.  In 
eighty-one  cases  not  operated,  35.91  per  cent.  died. 

Combining  both  Durham's  and  Gross's  tables,  24.48  per 
cent,  of  those  operated  died.  The  statistics  of  Gross  and  Dur- 
ham favor  operation,  while  those  of  Weist  favor  the  expectant 
treatment. 

Reclus  states  that  if  the  foreign  body  becomes  encysted,  op- 
eration is  not  necessary;  but  if  suppuration  sets  in,  it  must  be 
treated  surgically.  Quincke  believes  that  foreign  bodies  should 
be  removed  immediately;  of  seven  cases  two  were  cured,  two 
improved,  and  three  died.  Hoffman  reports  one  hundred  and 
forty-seven  cases ;  forty-six  were  cured  by  coughing  up  the 
foreign  body ;  seven  by  the  foreign  body  rupturing  externally ; 


346  THE  SURGERY  OF  THE  LUNGS 

twenty-six  through  tracheotomy  and  extraction ;  eleven  died  in 
spite  of  tracheotomy;  one  died  in  spite  of  pneumonotomy ; 
fifty-two  were  unoperated;  one  improved  unoperated;  and 
three  uncertain  were  unoperated. 

Freyan  collected  nine  operated  cases;  four  died,  four  im- 
proved, one  was  cured.  Fowler  (1874)  had  a  case  of  aspi- 
rated tooth,  with  formation  of  abscess  at  base  of  right  lung; 
pneumonotomy  was  performed,  followed  by  recovery. 

Nothnagel's  "  Encyclopedia  of  Practical  Medicine,"  Amer- 
ican Edition,  1902,  p.  39,  records  thirteen  cases  of  metal,  glass, 
coins,  and  bullets  in  the  bronchus ;  there  were  eight  tracheoto- 
mies, with  no  deaths ;  no  treatment  in  five,  with  one  death.  It 
also  records  sixty-five  cases  of  needle,  bone,  or  splinters,  with 
twelve  tracheotomies  and  five  deaths;  twenty-five  cases  with- 
out treatment  and  fourteen  deaths ;  two  where  the  foreign  body 
was  extracted  with  forceps  through  the  mouth.  In  fifteen 
cases  of  hard-fruit  seeds  that  do  not  sw^ell  in  water,  there  were 
five  tracheotomies  with  three  deaths ;  three  cases  w'ithout  treat- 
ment, and  two  deaths. 

In  seventeen  cases  of  other  foreign  bodies,  there  were  two 
tracheotomies  with  one  death ;  six  cases  w^ithout  treatment,  and 
five  deaths.  The  report  of  ninety  cases  of  miscellaneous  for- 
eign bodies,  gives  thirty-five  tracheotomies  with  five  deaths; 
one  case  of  laryngotomy  with  recovery ;  four  cases  of  laryngo- 
tracheotomy  with  no  deaths ;  thirty  cases  without  treatment  and 
twelve  deaths ;  five  cases  of  thoracoplasty  wuth  one  death,  and 
finally  four  cases  of  removal  of  foreign  body  with  forceps, 
where  all  recovered. 

Diagnosis — Goodlee's  contribution  "On  the  efifects  pro- 
duced by  retention  of  foreign  bodies  for  lengthened  periods  in 
the  bronchial  tubes,"  shows  that  the  symptoms  usually  follow  a 
definite  course ;  cough,  expectoration,  which  becomes  foetid, 
pleurisy,  emaciation,  bronchopneumonia,  and  gangrene. 
These  observations  are  corroborated  by  those  of  Fowler.  But 
some  of  these  symptoms  are  variable.     That  is,  there  may  be, 


FOREIGN   BODIES  347 

or  there  may  not  be,  expectoration  of  any  character.  There 
may  be  temperature,  with  or  without  pus,  accompanied  with 
rigors,  occasionally.  There  may  be  no  emaciation,  but  the  rule 
is,  emaciation,  if  the  foreign  body  is  allowed  to  remain.  When 
a  foreign  body  is  of  a  sufficient  size  to  remain  fixed  in  the  air 
passages,  "  there  is  great  ^dyspnoea,  violent  cough,  lividity  of  the 
countenance,  writhing  of  the  patient."  Until  the  body  is  ex- 
pelled, or  descends  into  the  lung,  there  will  be  variable  lulls,  fol- 
lowed by  a  recurrence  of  symptoms. 

F.  T.  Stewart  (Philadelphia  Medical  Journal,  December 
15,  1900,  p.  1131)  says:  "Diminished  inspiratory  dilatation  of 
one  lung,  and  retention  of  resonance,  with  diminished  vesicular 
murmur  and  vocal  fremitus  can  only  be  caused  by  the  constric- 
tion of  a  bronchus,  or  pneumothorax.  The  exact  spot  may  be 
determined,  if  on  repeated  examinations,  a  whirring  bronchus 
occupies  the  same  place,  together  with  fixed  pain  and  palpable 
thrill  over  a  spot  corresponding  to  a  bronchus." 

The  presence  of  a  foreign  body  in  the  lung  can  usually  be 
detected  by  auscultation.  There  is  but  little  difference  in  this 
respect  whether  the  object  enters  the  lung  by  passing  through 
the  trachea,  or  passing  directly  through  the  chest  wall.  Percus- 
sion of  the  affected  area  will  at  times  elicit  dulness.  There 
may,  or  may  not  be  mucous  rales,  or  pain.  The  respiratory 
sound  may  be  present,  or  it  may  be  absent.  If  the  foreign  body 
completely  closes  the  bronchus,  the  respiratory  sound  is  lost 
beyond  the  obstruction,  but  the  pulmonary  resonance  will  be 
normal.  The  same  thing  is  true  if  an  abscess,  or  a  cyst  of 
any  character,  has  resulted  from  the  presence  of  a  foreign  body. 
Under  these  circumstances  the  object  will,  almost  invariably,  be 
found  within  the  cavity.  There  is  also  more  or  less  induration 
in  the  neighborhood  of  the  body,  during  the  earlier  stage  of  its 
presence.  This  is  especially  true  in  cases  where  an  abscess  of 
any  character  has  formed. 

Rushmore  was  among  the  first  to  attempt  to  remove  a  for- 
eign body  from  a  lung  by  opening  the  chest  wall,  and,  although 


348  THE  SURGERY  OF  THE  LUNGS 

the  patient's  condition  would  not  permit  him  to  complete  the 
operation,  due  credit  must  be  given  him.  This  operation 
should  be  attempted  only  after  all  other  methods  have  failed. 

The  X  ray  will,  perhaps,  locate  the  body,  and  if  once  lo- 
cated, all  other  things  having  failed,  and  there  being  great 
danger  of  death,  then  the  chest  wall  should  be  opened. 

Bronchiotomy  must  have  been  done  very  early,  for  we  are 
told  that  Aretaeus  of  Cappadocia,  a.d.  50-80,  brought  the  oper- 
ation into  disuse. 

The  possibilities  of  bronchiotomy  in  the  right  side  are 
greater  than  in  the  left,  as  shown  by  anatomical  research. 
Whether  the  bronchi  should  be  reached  from  in  front,  or  be- 
hind, is  perhaps  a  question.  However,  the  incision  should  be 
made  in  the  long  axis  of  the  tube ;  the  tube  once  opened,  should 
not  be  closed  except  by  packing,  and  the  use  of  a  drainage  tube. 

In  this  connection  the  experiments  of  Dr.  De  Forrest  Wil- 
lard  with  reference  to  opening  the  bronchi  for  the  removal  of 
foreign  bodies  should  be  consulted.  ("Transactions  of  the 
American  Surgical  Association,"  Volume  IX,  p.  345.) 

When  it  has  been  decided  that  an  operation  (brochiotomy) 
is  necessary,  the  incision  in  the  chest  wall  should  be  made  as 
near  as  possible,  and  over,  or  above,  the  approximate  position 
of  the  foreign  body.  In  order  to  determine  the  exact  location 
of  the  foreign  body,  the  lung  should  be  palpated  with  the  fin- 
ger, unless  the  body  is  exceedingly  small,  or  near  the  base  of 
the  lung.  The  induration  of  the  lung  tissue,  which  always  oc- 
curs in  the  area  surrounding  the  foreign  body,  will  also  aid  in 
locating  it.  When  the  area  has  been  found  by  palpation,  or  by 
introducing  a  very  small  exploring  needle  here  and  there,  that 
portion  of  the  lung  should  be  brought  to  the  chest  wall  and  al- 
lowed to  unite.  The  union  will  be  completed  in  four  or  five 
days.  In  doing  this  a  good  opportunity  is  offered  to  open  the 
lobe  and  remove  the  foreign  body.  It  also  offers  greater  ad- 
vantages for  controlling  hsemorrhage  directly,  by  packing.  The 
cut  surfaces  of  the  lungs  would  sooner  or  later  become  adherent 


Plate  XLIX. 


-1    ■ ,    -•'    ^ 


X  1U(J(J. 

DiPLOCoccus,  (Fraenkel). 


•^  • 


y 


X   lUUU. 

Bacillus   Tuberculosis. 


(Chapter  on  Bacilli.) 


FOREIGN    BODIES  349 

in  any  case.  This  mode  of  procedure  also  allows  great  facili- 
ties for  subsequent  exploration.  The  amount  of  rib  tissue  to  be 
removed  depends  upon  the  size  of  the  area  affected,  and  its 
location  in  the  lobe. 

For  an  explanation  of  the  frequency  of  foreign  bodies  in  the 
right  and  left  lungs,  one  must  refer  to  the  combined  tables  of 
Gross,  Cheedle,  Saunders,  Beleg,  and  Bourdillat,  in  which  one 
hundred  and  fifty-six  cases  are  given,  with  ninety-eight  in  the 
right  lung,  and  fifty-eight  in  the  left.  The  right  bronchus  is 
wider  and  shorter  than  the  left,  and  is  made  up  of  from  four  to 
six  rings.  There  can  be  no  special  reason  given  why  foreign 
bodies  should  lodge  oftener  in  the  right  than  in  the  left.  The 
left,  however,  is  more  perpendicular  than  the  right,  although 
slightly  smaller  in  circumference.  This  difference  should  cause 
foreign  bodies  to  enter  the  left  bronchus  more  frequently  from 
gravity  alone.     (See  Chapter  on  Anatomy.) 

Christovitch  {Revue  de  Chirurgie,  Paris,  July  lo,  1900), 
removed  a  ball  from  the  lung,  six  days  after  its  entry.  He  re- 
sected the  fifth  and  sixth  ribs  at  the  point  of  the  lung  containing 
the  ball,  and  delivered  it ;  the  wall  of  the  cyst  was  incised  and 
blood  and  pus  escaping,  the  cavity  was  tamponed  with  gauze 
and  the  chest  cavity  drained ;  recovery  ensued  in  sixty  days. 

Curtis  in  1896  employed  posterior  thoracotomy  for  a  for- 
eign body  in  the  bronchi.  He  resected  portions  of  the  fourth, 
fifth  and  sixth  ribs  subperiostially  and  outwardly  from  the 
tuberosities.  He  divided  the  periosteum  and  intercostal  mus- 
cles so  as  not  to  injure  the  pleura.  The  latter  was  detached  to 
give  access  to  the  root  of  the  lung.  The  bronchus  was  not 
opened  until  the  following  day  because  of  patient's  condition. 
Not  succeeding  with  the  forceps,  he  incised  the  lung  down  to 
the  object.  He  was  again  forced  to  discontinue  the  operation. 
The  patient  died  forty-eight  hours  later  from  pre-existing 
pneumonia.  ("Annals  of  Surgery,"  Volume  XHI,  1895,  p. 
605.) 

Dr.   E.   D.   Ferguson    {American   Medicine,   February    i, 


350  THE    SURGERY   OF   THE    LUNGS 

1902,  p.   194)  records  a  case  of  a  Durham  tube  in  the  right 
bronchus.     It  was  removed  through  an  incision  in  the  right 
neck  extending  through  the  isthmus  of  the  thyreoid  to  a  point 
near  the  bifurcation  of  the  bronchus.     The  patient  recovered. 
( See  Chapter  on  Lacerated  and  Incised  Wounds. ) 


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XXII,  p.  137. 
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(1891),  1893,  69. 
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137- 
Kobler,  Wiener  Klin.  Rundschau,  1895. 
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Wade,  Lancet,  London,  1895,  II,  499. 
Morgan,  Lancet,  London,  1895,  II,  769. 


Plate  L. 


X  200. 

Actinomyces. 


VJi,, 


-%:• "-  '-^v 
i^&^^^^-&^ 


X  3S0. 
Aspergillus,  (In  Lung  of  Cow). 


(Chapter  on   Parasitic  Fungi.) 


FOREIGN   BODIES  355 

WiNANDS,  Munchen  Medicin.  Woch.,  1895,  XIII,  121 1. 
Murray,  Ann.  Surg.,  Philadelphia,  1895,  XXII,  p.  519. 
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Vols.  47,  54,  55. 
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Hall,  Univ.  Medical  Magazine,  Philadelphia,  1895-96,  VIII,  527. 
Mandowski,  Deutsche  Medicin.  Wochenschr.,  1895,  XXI,  479-481. 
Glasgow,  Virginia  Medical  Monthly,  Richmond,  1895-96;  XXII, 

55-58. 
Carslaw,  Glasgow  Medical  Journal,  1895,  XLIII,  274-280. 
Rogers,  Memphis  Medical  Monthly,  1895,  XV,  97-102. 
Andreyeff,  Feldscher,  St.  Petersburg,  1896,  VI,  376. 
Crumbine,  Cincinnati  Lancet-Clinic,  1896,  n.  s.,  XXXVII,  648. 
Hough,  Quart.  Medical  Journal,  Sheffield,  1896-97,  245-248. 
Thomas  and  Junod,  Revue  Midicale  de  la  Suisse  Rom.,  Geneve, 

1896,  XVI,  246-254. 
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LXXIV,  1895. 
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Laudau,  Therapeut.  Wochenschr.  Wien,  1896,  III. 
Thompson,  National  Medical  Review,  Washington,  1896-97,  VI, 

280-1. 
Massei,  Arch.  Ital.  di  Laryngol.,  Naples,  1896,  XVI,  125-133. 
Heindl,  Wien.  Klin.  Wochenschr.,  1896,  IX,  832. 
Koch,  Afin.  de  Mai.  de  r Oreille  et  du  Larynx,  Paris,  1896,  XXII,  p. 

II,  295-307. 
Binswanger,  Medical  Sentinel,  Portland,  Oregon,  1896,  ^,329. 
Farmer,  Country  Doctor,  Sparta,  Tennessee,  1897,  IV,  16-19. 
HoGNER,  Eira,  Stockholm,  1897,  XXXI,  385. 
Lavrand,  Journal  d.  Science  Med.  de  Lille,  1897, 1,  32,  35. 
Archer,  Lancet,  London,  1897,  I,  1146. 
Marshall,  British  Med.  Jour.,  London,  1897, 1,  p.  11 58. 
Francis,  British  Med.  Jour.,  London,  1897,  II,  809. 
Himmelsbach,  Buffalo  Med.  Jour.,  1897-98,  XXXVII,  p.  19. 
Hough,  Quart.  Med.  Jour.,  Sheffield,  1896-97,  VI,  245-8. 


356  THE  SURGERY  OF  THE  LUNGS 

Crumbine,  Yale  Med.  Jour.,  New  Haven,  1896-97;  III,  137. 
KoLLOFRATH,  Mufichen  Medicin.  Wochenschr.,  1897,  XLIV,  1038. 
Fulton,  Med.  Rec,  New  York,  1897,  LI,  264. 
ScHiFFERS,  Ann.  Soc.  de  Med.  Chir.  de  Lihge,  1897,  XXXVI,  75. 
BoNNUS,  Bull,  et  Mem.  Societe  Med.  des  Hop.  de  Paris,  1897,  35, 

Vol.  XIV,  1 2 14-12 1 7. 
NoRDMAN,  Jour,  de  Med.  et  Chir.  Prat.,  Paris,  1897,  LXVIII,  772- 

775- 
Meyjes,  Jour.  Laryngol.,  London,  1897,  XII,  599-602. 

Bunch  and  Lake,  Lancet,  London,  1897,  II,  784-6. 

Marmasse,  Rev.  Prat.  d'Obst.  et  de  Pediat,  Paris,  1897,  X,  80-82. 

PoNCHON,  Rev.  Prat.  d'Obst.  et  de  Pediat,  Paris,  1897,  X,  25-30. 

NoLTERius,  Arch.  }.  Laryngol  u.  Rhinol,  Berlin,  1897,  VI,  154-156. 

Wyman,  Phy.  and  Surg.,  Detroit  and  Ann  Arbor,  1897,  XIX,  198- 

207. 
Koch,  Wiener  Klin.  Rundschau,  1897,  IX,  72-74. 
Barbat,  Med.  Rec,  New  York,  1898,  LIV,  172. 
Aynoly,  British  Med.  Jour.,  London,  1898,  II,  159. 
Fronz,  Jahrb.  }.  Kinderheil.,  Leipzig,  1898,  XLVII,  74-89. 
Moscucci,  Rijorma  Med.,  Naples,  1898,  XIV,  124-7. 
Vertogradoff,  Voyenno  Medical  Journal,  St.  Petersburg,  1898, 

CXCII,  651-662. 
Peyrissac,  Rev.  Hebdom.  de  Laryngol,  etc.,  Paris,  1898,  XVIII, 

1-14. 
Felizet,  Bull,  et  Mem,  Societe  de  Chir.  de  Paris,  1898,  n.  s.,  XXIV, 

pp.  522,  524. 
Horn,  Journal  American  Medical  Association,  Chicago,   1898, 

XXXI,  137. 
Battle,  North  Carolina  Medical  Journal,  Winston,  1898,  XLI, 

409,  413. 
Briquet,  Journal  de  Med.  et  Chir.  Prat.,  Paris,  1898,  LXIX, 

369-372. 
Heller,  Miinchen  Med.  Wochenschr.,  1898,  XLV,  877. 
Lenden,  Intercolon.  Medical  Journal,  Australas.,  Melbourne,  1898, 

III,  132-142. 
Packard,  Tr.  Path.  Soc.  Philadelphia,  1898,  XVIII,  273-5. 


FOREIGN    BODIES  357 

Havermann,  Deutsche  Zeitschr.  }.  Chir.,  Leipzig,  1898,  1899,  I, 

401-403. 
Curtis,  Ann.  Surg.,  Philadelphia,  1898,  XXVIII,  605-610. 
Verco,  Australas.  Med.  Gaz.,  Sydney,  1898,  XVII,  209-11. 
Gomez  de  la  mata,  Ann.  du  Mai.  de  I' Oreille  et  du  Larynx,  Paris, 

1898,  XXIV,  636-640. 
WiGG,  Australas.  Medical  Gazette,  Sydney,  1898,  XVII,  171. 
Gibson,  Australas.  Medical  Gazette,  Sydney,  1898,  XIV,  47-  50. 
Winter,  Duodenum-Helsonki,  1898,  XIV,  381-385. 
Smith,  Maritime  Medical  News,  Halifax,  1899,  XI,  19. 
Coon,  New  York  Med.  Jour.,  1899,  XLIX,  270. 
Moffatt,  British  Med.  Jour.,  London,  1899,  I,  531. 
Java,  Med.  Rec,  October  7,  1899,  p.  514. 
Warrack,  British  Med.  Jour.,  1899,  Vol.  I,  p.  401. 
Haussay,  Arch,  de  Medicine  d'Enj.,  Paris,  1899,  II,  99-101. 
Mathew,  British  Med.  Jour.,  1901,  Vol.  I,  p.  888. 
Hecker,  Munchen  Med.  Wochenschr.,  1900,  XL VII,  1132-1134; 

Journal  American  Medical  Association,  1900,  XXXIV,  435- 

436- 
WiLLARD,   DE  FoREST,  Joumal  American  Medical  Association, 

October,  26,  1901. 
Fisher,  Lancet,  London,  I,  244-245,  i,  Fig.  1901. 
Fiessinger,  Journal  de  Medecine,  Paris,  July-September,  1902. 
Archard,  Frorieps  Notizen,  Vol.  5,  p.  302. 
KiscHENSKi,  Med.  Obozr.,  Moscow,  1900,  LIV,  849-861 ;  2  Fig. 
ZuiNCKE,  Journal  American  Medical  Association,  March  22,  1902, 

Vol.  XXXVIII,  No.  12,  p.  798. 
HuBER,  Philadelphia  Med.  Jour.,  1902,  IX,  803-805;  i  Fig. 
Gardner,  British  Med.  Jour.,  London,  1902, 1,  835. 
Hughes,  Indian  Med.  Rec,  Calcutta,  1902,  XXII,  94. 
Ferguson,  American  Medicine,  1902,  p.  194. 


CHAPTER    VIII 
ABSCESS— BRONCHIECTASIS 

Abscess  of  the  lung  may  be  due  to  many  causes,  foreign 
bodies  received  through  the  trachea,  infected  cysts  or  otherwise, 
but  more  especially  to  tuberculosis. 

Abscess  is  one  of  the  most  frequent  surgical  lesions  of  the 
lung.  It  is  also  the  one  pulmonary  disease  which  yields  most 
readily  to  surgical  treatment.  It  may  be  single  or  multiple 
when  due  to  any  cause,  and  is  more  frequently  multiple  when 
of  tuberculous  origin.  The  base  of  the  lungs  is  the  most  fre- 
quent location  when  tuberculous,  while  non-tuberculous  abscess 
is  less  frequently  found  in  this  locality.  One  or  all  lobes  of  one 
or  both  lungs  may  contain  one  or  more  abscesses  at  the  same 
time. 

Historical  (1710-1903). — Purman  (1692)  says  that  chest 
and  lung  incisions  are  necessary  for  hsemothorax,  chest  wounds, 
cavities  of  lung,  etc.  Bligny  ( 1670)  reports  a  case  of  phthisis 
which  recovered  after  an  accidental  sabre  cut.  Balgious 
(1710)  was  one  of  the  first  to  treat  wounds  of  the  lung  by  in- 
cising the  pleura.  He  also  advised  the  same  for  phthisis  ab 
ulcere  pulmonis.  Bligny  (1720) ,  Barry  and  Boerhave  (1726) 
advocated  opening  tuberculous  abscesses ;  and  Campara- 
don  (1760)  treated  a  case  of  abscess  of  the  right  lung  and  cured 
it  by  surgical  intervention.  Sharpe  (1769)  says  severance  of 
adhesions  is  not  necessary ;  the  cavity  should  be  simply  punct- 
ured with  a  lancet  and  drained.  Pontean  (1783)  cured  a  case 
of  abscess  of  the  lung  by  incising  it  through  the  pleural  adhe- 
sions as  suggested  by  David  (1780). 

358 


ABSCESS — BRONCHIECTASIS  359 

Among  the  first  cases  is  one  reported  in  1753,  in  Porter's 
essay  on  "  Abscess  of  the  Lung."  {Journal  American  Medical 
Association,  March  7,  1891.)  Gumprecht  (1793)  reported  a 
case  of  abscess  of  the  king  treated  surgically.  Richeraud 
incised  a  lung  abscess  with  success.  Faye  (1797)  cured  an 
abscess  by  operation,  but  recovery  was  slow.  Bell  (1805)  re- 
ports one  cured  case  and  several  failures.  Jaymes  (181 3)  re- 
ports cured  cases,  while  Callisen  (1815),  Nasse  (1824-1844), 
advise  operation  for  abscess ;  Nasse  reporting  successful  cases. 

Zaug  (1818)  reported  eight  cases  of  incised  lung  abscesses, 
Hawthorne  ( 1819)  reported  a  case  of  abscess  cured  by  paracen- 
tesis, and  Samson  (1829)  had  a  case  of  abscess  in  which  he 
opened  the  lung;  the  patient  died.  Stokes  ( 1832)  cured  an  ex- 
tensive pulmonary  abscess  by  cicatrization;  death  resulted  a 
year  after  from  acute  pleuropneumonia.  It  was  found  that  a 
portion  of  the  lung  had  been  isolated,  from  the  inflammatory 
action  of  the  cicatrix. 

Say  re  (1842)  reported  a  case  of  abscess  from  pneumonia 
of  the  left  lung  in  a  tuberculous  patient,  which  terminated 
favorably  by  forming  a  fistulous  opening  between  the  third  and 
fourth  ribs,  and  an  abscess  in  the  substance  of  the  lung.  Hast- 
ings (1844)  is  the  first  to  mention  the  treatment  of  tuberculous 
cavities.  He  reported  two  cases,  entitling  the  first,  "  Tuber- 
culous excavation  of  the  lung,  treated  by  perforating  the  cavity 
through  the  wall  of  the  chest."  The  second  case  was  treated  by 
puncturing  the  tuberculous  cavity. 

Among  the  first  to  adopt  energetic  surgical  treatment  for 
pulmonary  abscess  was  Robinson  (1844).  Graux  of  Brus- 
sels (1850)  reported  thirteen  successive  operations  with  fatal 
results.  After  the  lapse  of  several  years  we  find  Dickson 
(1851)  going  back  to  Hawthorne's  treatment  of  paracentesis 
for  abscess  of  the  lung.  Fowler  (1852)  had  a  case  of  pneu- 
monia terminating  in  abscess.  From  the  autopsy  it  was  found 
that  rupture  irito  the  pleural  cavity  had  occurred. 

Hale  (1855)  gives  details  of  a  case  requiring  removal  of 


360  THE  SURGERY  OF  THE  LUNGS 

the  left  lung.  Goodwin  (1857)  had  a  case  of  facial  paralysis, 
followed  by  pleuropneumonia  terminating  in  gangrenous  ab- 
scess of  the  lung,  opening  externally.  Bristowe  (1857)  re- 
ported a  case  in  which  a  gangrenous  cavity  behind  the  root  of 
the  lung  opened  into  the  left  bronchus  and  oesophagus. 

Catheterization  of  the  air  passages  was  done  by  Greene 
(i860).  This,  perhaps,  influenced  more  or  less  the  intra- 
pulmonary  injections  which  followed.  Shann  (1861)  had  a 
case  of  large  abscess  in  the  right  lobe  opening  into  the  right 
lung,  expectoration  of  large  quantities  of  purulent  matter,  and 
subsequent  external  evacuation.     The  patient  died. 

Evans  (1861)  reports  a  case  of  abscess  of  the  lung  from 
the  presence  of  a  foreign  body.  Evacuation  was  practised 
through  the  bronchial  tubes  and  through  the  thoracic  w^alls. 
Sir  H.  Cooper  (1861)  had  a  similar  case.  W.  Koch,  Hiller, 
and  Mosler  injected  medicaments  into  the  lung.  Mosler  and 
Hunter  ( 1873)  opened  an  abscess  cavity  of  the  right  upper  lobe 
of  the  lung  in  the  third  intercostal  space,  and  introduced  a  drain- 
age tube,  through  which  the  pus  escaped  and  through  w'hich  a 
carbolic-acid  solution  w-as  injected  into  the  cavity. 

Curran  reported  an  abscess  of  the  right  lung  bursting 
through  the  diaphragm  and  umbilicus.  E.  D.  Payne  (1873) 
reported  a  case  of  abscess  of  the  lung,  discharging  by  the 
mouth,  and  through  an  external  opening  in  the  walls  of  the 
chest.     In  this  case  the  patient  recovered. 

Saunders  (1873)  treated  a  traumatic  pulmonary  abscess  by 
injections  of  carbolic  acid.  Hutchinson  (1873)  also  advocated 
the  local  treatment  of  pulmonary  cavities  by  injections  through 
the  chest  walls.  Pepper  (1873)  speaks  of  the  local  treatment 
of  pulmonary  cavities. 

Aguilar  ( 1876)  reported  a  case  of  pulmonary  abscess  cured 
by  a  surgical  operation.  Previous  to  this,  our  knowledge  of 
the  surgical  treatment  of  the  lungs  w-as  greatly  increased  by  the 
publication  of  Koch's  "  Historische  iiber  die  Chirurgie  des  Be- 
handlung  der  Lungen  Caverne."     The  use  of  antiseptic  treat- 


Plate   LI. 


X  500. 
Aspergillus  Fumigatus,  (in  Lung), 


X  1.50. 
]\lYCELiu:\r  OF  Aspergillus,   (in  Lung-). 

(Chapter  on   Parasitic   Fungi.) 


ABSCESS — BRONCHIECTASIS  361 

ment  following  Lister's  great  discovery  was  not  always  suc- 
cessful at  first. 

Ferol  and  Gauze  (1877)  reported  a  case  of  granular  per- 
foration of  a  lung  cavity,  with  general  emphysema  from  an 
abscess  in  the  neighboring  intercostal  space.  Powell  (1877) 
reports  a  successful  case  of  excavation  of  the  lung  in  phthisis. 
Ballin  (1877)  reported  his  observations  of  a  case  of  pneumo- 
thorax in  consequence  of  a  lobular  abscess  of  the  lung  that  was 
spontaneously  cured.  Baldwin  reported  a  case  of  abscess  of 
the  lung  from  mechanical  irritation. 

We  have  the  report  of  Powell  and  Lydell  (1880)  on  the 
treatment  of  a  basic  cavity  by  paracentesis.  Sutton  (1881) 
published  reports  of  like  cases,  and  Payne  reported  a  case  of 
pulmonary  abscess  opened  antiseptically,  which  ended  fatally. 
Beale  reported  a  case  which  he  treated  by  incising  and  dressing, 
and  Fenger  and  Hollister  opened  and  drained  cavities  (1881). 

The  Gulstonian  Lectures  of  1882  are  valuable,  as  they  give 
a  resume  of  the  world's  knowledge  on  the  origin,  growth  and 
repair  of  the  lungs.  Ewart  also  reported  cases  of  pulmonary 
abscess,  and  Grijourer  (1883)  reported  two  cases  of  pulmonary 
metatastic  abscesses  treated  by  incision  around  the  bronchi. 
Phillips,  however,  goes  back  to  a  method  favored  greatly  during 
the  preceding  decade,  when  he  reports  two  cases  of  intrapul- 
monary  injection. 

Bull  reports  a  large  bronchiectatic  cavity  of  the  right  base 
in  the  ninth  intercostal  space ;  he  opened  the  lung  with  cautery 
and  finger;  pus  escaped  through  a  fistula  and  death  resulted. 
At  the  autopsy,  numerous  bronchietatic  cavities  were  found. 
Bliss  ( 1884)  describes  a  similar  operation,  and  Krimes,  Briche- 
ton,  and  Brochert  report  operations  for  lung  abscess. 

Black  (1885)  was  one  of  the  first  of  recent  operators  to  ex- 
cise a  tuberculous  apex.  The  patient  died,  and  on  being  cen- 
sured severely  by  the  coroner.  Black  committed  suicide. 

Somers  and  Hochsinger  (1889-90)  reported  cases;  Rick- 
etts  (1889)  made  three  pneumonotomies  to  drain  tuberculous 


362  THE   SURGERY   OF   THE   LUNGS 

and  traumatic  abscesses.  Osier  (1889)  reported  a  case  of  an 
abscess  cavity,  resulting  from  bronchiectasis  in  the  left  lung, 
being  incised  with  fatal  results.  Standhartner  (1890)  had  a 
case  of  metastatic  pulmonary  abscess  which  perforated  the 
oesophagus ;  a  very  interesting  paper  was  published  by  Taefurt 
(1891),  entitled  "  Uber  Lungenchirurgie."  Greene  (1891)  re- 
ported a  case  of  pulmonary  abscess  cured  by  surgical  treatment ; 
Murram  (1891)  reports  a  case  of  peribronchial  abscess;  Por- 
ter ( 1891 )  a  case  of  abscess  ;  Tietze  ( 1891 )  speaks  of  an  opera- 
tion upon  the  lung.  Kerchoff  and  Rochard  (1892)  described 
their  mode  of  aspirating  the  lung.  Prey's  contributions  to  the 
study  of  lung  abscesses  are  of  great  value. 

Jacobi's  report  (1891)  shows  that  the  Americans  were  ac- 
tively engaged  in  lung  surgery.  Hawkins  (1891)  reported  a 
case  of  abscess  of  the  lung,  probably  of  pneumonic  origin,  with 
drainage  and  recovery. 

Huber  (1892)  wrote  on  "Abscess  of  the  Lung;"  Tuffier 
(1892)  resected  the  summit  of  the  right  lung  for  tuberculosis, 
with  recovery  at  the  end  of  eight  months;  again  in  1893  he 
made  a  pneumonectomy.  Antony  (1892)  employed  pleurot- 
omy  in  a  case  of  tuberculous  pleurisy.  Andrews  (1892)  em- 
ployed the  same  operation  in  a  case  of  abscess  of  the  right  lung, 
and  secured  removal  of  a  large  calcareous  deposit  through  the 
chest  wall.  White  (1892)  also  used  pneumonotomy  for  the 
relief  of  a  tuberculous  abscess  and  gangrene  of  the  lung  tissue. 
Salmoni  (1892)  employed  resection  in  a  case  of  tuberculous 
ulceration  of  the  right  lung.  Hofmokl  (1892)  devotes  much 
thought  to  pneumonotomy  for  drainage  in  case  of  putrid  bron- 
chitis. 

Tuffier  mentions  (1893)  a  "pneumonotomie"  for  bronchiec- 
tasis of  the  apices  of  the  right  lung.  Pickard  (1893)  made  a 
pleurotomy;  while  Trzebicky  (1893)  wrote  a  very  interesting 
paper  on  lung  surgery. 

Pitt's  ( 1893)  address  on  the  surgery  of  the  air  passages  and 
thorax   in  children,  was  among:   the  first  on  this  branch  of 


ABSCESS — BRONCHIECTASIS  363 

surgery  in  the  young.  Matignon  (1893)  wrote  a  paper  on 
pneumonotomy  for  abscess  of  the  lungs.  Shurly  (1893)  pub- 
Hshed  his  paper  on  the  artificial  opening  of  the  pulmonary  cav- 
ities, the  insertion  of  a  rubber  tube,  and  the  injection  of  chlo- 
rine gas.  Huber  ( 1893)  reported  a  case  of  abscess  in  the  lung 
of  a  child  thirteen  and  one-half  months  old,  with  operation  and 
recovery.  Voje  (1893)  also  reported  a  case  of  abscess  of  the 
lung. 

Matignon  (1894)  wrote  a  second  paper  on  pneumonotomy. 
Makay  reported  ( 1894)  notes  on  a  case  of  abscess  in  the  lung; 
with  haemoptysis,  followed  by  pneumonotomy  and  death. 
Leach  operated  upon  a  gangrenous  abscess  of  the  lung  with 
perfect  success.  For  those  interested  in  this  subject,  Roches- 
ter's report  will  be  found  of  value.  He  published  an  account  of 
three  cases  of  lung  abscess,  with  comments  upon  the  aetiology, 
diagnosis,  and  treatment.  Apolant's  name  must  also  be  added 
to  the  list  of  those  reporting  cases. 

Kauffmann  (1894)  published  cases  of  pulmonary  abscess 
simulating  empyema.  Maragliano  reported  a  case  of  pul- 
monary abscess,  ulceration,  and  pleuropyopneumothorax.  The 
surgery  of  pulmonary  abscess  was  given  prominence  by  Bre- 
den's  published  works. 

The  knowledge  of  the  surgical  treatment  of  lung  abscess 
was  greatly  advanced  by  the  publications  of  Krause,  Chadwick, 
and  Kudintseff  (1895). 

Tuffier  ( 1895)  employed  resection  of  apex  of  right  lung  for 
relief  in  a  case  of  phthisis.  Anderson  (1895)  reported  a  case 
of  chronic  abscess  of  the  lung.  Hitzig's  paper  on  the  influence 
of  the  influenza  bacillus  in  causing  lung  abscess  is  of  much 
interest.  Webb  treated  abscess  of  the  lung  by  drainage  and 
iodoform ;  the  patient  recovered.  Rody's  case  was  an  abscess 
of  the  lung  following  fibrous  pneumonia  (pyopneumothorax)  ; 
thoracotomy  was  performed  and  was  followed  by  recovery. 
Walton  also  employed  pneumonotomy  in  abscess  of  the  lung 

Sicard  (1897)  reported  cases  of  pulmonary  abscess.  Beck's 


364  THE  SURGERY  OF  THE  LUNGS 

diagnosis  and  treatment  of  abscess  of  the  lung  is  of  great  inter- 
est. Matthew  ( 1897)  had  a  case  of  lung  abscess  and  Reynaud 
reported  a  case  of  pulmonary  abscess  and  connective  sclerosis. 
Clark  (1897)  operated  for  abscess  of  the  lung  and  Edwards 
(1897)  reported  favorable  results  from  his  operation.  North- 
rop successfully  operated  in  a  case  of  abscess  of  the  lung. 
Crespin  reported  a  case  of  la  grippe,  bronchitis,  pyopneumo- 
thorax ("  pleurotomie  ").  Kijenski  employed  pneumonotomy 
with  success  in  abscess  of  the  lung.  Moore  operated  success- 
fully in  lung  abscess. 

Withing  (1898)  reported  on  pulmonary  abscess  and  gan- 
grene. Lichtenauer  (1898-99)  reported  a  case  in  which  he 
employed  pneumonotomy  for  a  case  of  cavity  of  the  lung 
combined  with  a  fistula  of  the  lung.  Solomon  (1899)  re- 
ported his  contributions  to  lung  surgery.  Kar  reported  upon 
abscess  and  gangrene  of  the  lung,  while  Burgess  and  Halstead 
both  successfully  employed  surgery  in  the  treatment  of  lung 
abscess.  Mariani  (1898)  reported  cases  of  pulmonary  abscess 
and  Alexsleyeff's  report  on  this  disease  showed  his  great  inter- 
est in  all  connected  with  the  lung.  Schmidt  (1898)  reports  a 
case  of  lung  abscess  and  Hobart  operated  for  lung  inflamma- 
tion, and  lung  abscess. 

Lewis  reported  a  case  of  infection  of  the  lung  as  an  acci- 
dent in  aspiration  of  the  pleura,  Gailliard  employed  pneumonot- 
omy in  multiple  abscess  and  gangrene  of  the  lung,  Mariani  re- 
ported a  case  of  pulmonary  fibroids  in  connection  with  lung 
abscess,  and  Goodlee,  Kjos,  and  Eisner  bring  the  subject  up  to 
date  by  their  papers.  Morelli  (1898)  employed  resection  of 
pulmonary  cartilage  in  a  case  of  abscess  of  the  lung. 

Dr.  Le  Moyne  Wills  of  Los  Angeles  (1900)  operated  for 
abscess  of  the  lung.  His  experience  proves  the  advisability  of 
surgical  interference  in  such  cases.  Surgery,  he  claims,  oflfers 
the  only  means  of  relief,  and  the.  only  means  of  preventing  death 
from  the  absorption  of  septic  matter.  He  found  that  bruising 
the  pleura  with  the  fingers  will  produce  the  connection  with  the 


Plate  LIE. 


X  50. 

PXEUMOXOMYCOSIS. 


(Chapter  on  Parasitic  Fungi.) 


ABSCESS — BRONCHIECTASIS  365 

external  incision  which  some  surgeons  advise  in  lung  opera- 
tions. His  experience  shows,  that  in  such  cases,  gravity  drain- 
age renders  coughing  unnecessary. 

Gluck  of  Berlin  has  operated  fourteen  times  on  the  lung; 
seven  times  for  abscess,  and  seven  times  for  bronchiectasis.  All 
have  recovered,  or  are  recovering.  At  the  Ninth  German  Med- 
ical Congress,  April,  1901,  he  exhibited  some  of  his  patients. 
In  several  cases  he  removed  several  ribs  and  freely  opened  the 
lung,  in  some  cases  removing  much  of  the  lung  tissue. 

Safert  says  that  tuberculous  cavities  in  the  lungs  are  not 
due  to  tubercle  bacilli  or  streptococci  alone ;  there  must  always 
be  a  primary  tuberculous  lesion.  The  streptococci  will  then 
colonize  in  it,  and  the  combination  of  the  two  microorganisms 
results  in  the  production  of  a  cavity.  His  experiments  on  a 
great  number  of  cadavers  and  one  living  subject  have  resulted 
in  success.  He  resected  the  second  rib  from  the  sternum  to  the 
axilla,  located  the  cavity  by  palpation,  and  incised  its  wall. 
There  was  only  slight  bleeding,  and  no  disturbance  of  res- 
piration   (Journal    American    Medical    Association,    Volume 

XXXVH,  No.  5,  1901,  p.  355). 

See  chapters  on  Gunshot  Wounds,  Foreign  Bodies,  and 
Lacerated  and  Incised  Wounds  of  the  Lungs. 

Symptoms  and  Diagnosis. — They  are  certain.  The  abscess 
may  be  in  the  pleural  cavity  or  in  the  lung,  or  in  both.  It  simu- 
lates tuberculosis,  gangrene,  and  empyema.  The  presence  of 
pus  should  be  determined  before  opening  the  chest  wall,  with- 
out the  use  of  an  exploring  needle  if  possible,  as  general  infec- 
tion of  the  pleura  may  ensue.  One  must  depend  upon  physical 
signs  so  far  as  possible  in  locating  the  accumulation  of  pus. 
Temperature  is  not  to  be  relied  upon.  Some  writers  hold  bron- 
chiectasis to  be  hopeless,  but  this  is  not  verified  by  actual  dem- 
onstration. Diagnosis  is  only  certain  when  pus  is  found  in 
the  sputum.  It  is  sometimes  colored ;  the  reddish  or  brownish 
tinge  being  due  to  elastic  fibres.  Blood-corpuscles,  alveolar 
epithelium,  crystals  of  margarin,  or  cholesterin,  mould-fungi, 


366  THE  SURGERY  OF  THE  LUNGS 

and  various  bacteria  may  be  revealed  by  the  microscope,  depend- 
ing upon  the  causative  malady.  When  abscess  of  the  lung-  is 
a  complication  of  acute  pneumonia,  there  is  an  intermittent  rise 
in  temperature  and  marked  prostration. 

Four  forms  of  simple  abscess  have  been  recognized.  In  the 
first  kind  the  symptoms  remain  obscure  until  there  is  a  sudden 
discharge  of  purulent  matter.  The  second  form  resembles 
pleurisy  with  effusion.  The  third  form  is  closely  connected 
with  that  form  of  pneumonia  which  skips  from  one  lung  to  the 
other,  or  advances  slowly  from  lobe  to  lobe. 

The  prognosis  is  usually  unfavorable  when  the  abscess  oc- 
curs in  the  lung  as  a  complication  of  abscess  elsewhere.  The 
presence  of  elastic  fibres  in  the  sputum  always  indicates  abscess 
of  the  lung.  The  most  frequent  complication  of  abscess  of  the 
lung  is  pleurisy.  Subcutaneous  emphysema  is  occasionally 
found,  as  Senator  observed;  but  this  is  only  present  when  the 
lung  is  adherent  to  the  costal  pleura. 

Abscesses  due  to  pneumonia  are  the  most  favorable;  ab- 
scesses due  to  foreign  bodies  in  the  bronchus  most  fatal.  Tuf- 
fier  reports  twenty-three  of  forty-nine  cases  of  abscess  of  the 
lung  due  to  fibrinous  pneumonia.  He  says  that  eighty  per 
cent,  of  the  abscesses  are  found  in  the  lower  lobes.  Pneumonia 
more  frequently  follows  injury  and  operation  for  foreign  bod- 
ies in  the  lung,  than  for  incision  of  the  lung  for  abscess. 

Staphylococcus  pyogenes  aureus  can  be  many  times  de- 
tected by  cultures  in  the  blood,  when  it  cannot  be  found  in  the 
sputum.  Hitzig  maintains  that  abscess  in  the  right  lower 
lobe,  in  which  the  sputum  contains  elastic  fibres,  alveolar  epi- 
thelium, and  crystals  of  hematoidin  is  due  to  the  action  of  in- 
fluenza bacilli. 

Treatment  is  the  same  whatever  the  cause  may  be,  but  it  is, 
however,  more  favorable  when  but  one  bronchus  is  involved. 
It  is  safer  to  open  the  chest  and  palpate  the  lung  with  the  finger, 
than  to  introduce  an  exploring  needle  through  the  intercostal 
space,  and,  thereby  subject  the  patient  to  increased  possibility  of 


ABSCESS — BRONCHIECTASIS  367 

infection  with  its  subsequent  results.  Dr.  J.  B.  Murphy  says : 
"  You  can  palpate  the  lung  just  as  well  as  you  can  palpate  in  the 
pelvis,  and  you  can  locate  your  abscess  exactly.  Do  not  make 
the  mistake  of  endeavoring  to  reach  it  with  a  Paquelin  cautery, 
for  you  will  find  that  the  lung  will  retract  in  the  chest  out  of 
reach  of  the  cautery,  unless  an  incision  be  made  in  the  chest  wall 
large  enough  to  enable  you  to  seize  the  lung,  or  unless  it  be  ad- 
herent. You  will  have  but  little  oozing  in  these  cases  and  the 
abscess  will  heal  perfectly."  ("  Medical  Review  of  Reviews," 
Vol.  VII,  No.  I,  p.  16.) 

It  has  been  suggested  by  one  operator  that  the  parietal  and 
visceral  pleura  should  be  permitted  to  become  adherent  before 
incising  with,  or  without  the  cautery.  The  knife  is  made  to  fol- 
low a  hollow  needle  which  has  been  inserted  into  the  cavity, 
from  which  pus  has  been  removed  through  the  needle.  Para- 
centesis is  to  be  condemned  for  the  purpose  of  aspirating  pus  or 
injecting  antiseptics.  It  is,  however,  proper  to  use  paracentesis 
through  adhesions  or  an  open  chest,  but  incision  should  always 
be  employed  for  treatment.  There  is  less  difficulty  in  locating 
pathological  lesions  of  the  lung  with  the  finger  in  an  open  chest, 
when  there  are  no  adhesions  than  with  them,  because  the  lung 
does  not  contain  air.  In  such  a  case  another  opening  in  the 
chest  wall  can  be  made  directly  over  the  lesion,  and  thus  allow 
it  to  be  brought  into  or  out  of  the  chest  opening  for  drainage. 

A  counter  opening  in  the  chest  should  be  made  at  the  lowest 
point  for  gravity  drainage,  which  is  to  be  governed  by  the  posi- 
tion which  the  body  is  to  assume.  Opoland  claims  that  drain- 
age of  a  pulmonary  abscess  is  better  when  the  patient  is  recum- 
bent with  the  chest  lower  than  the  body. 

Abscess  of  the  posterior  surface  of  the  lung  is  very  inac- 
cessible, but  like  all  other  forms,  it  must  be  found  and  opened. 
If  in  the  apex,  a  portion  of  the  first  rib  should  be  removed,  the 
pleura  incised,  and  the  position  of  the  pus  cavity  determined. 
Resect  one  or  more  ribs  posteriorly,  the  fifth,  sixth,  or  seventh, 
or  all,  if  possible,  within  the  area  of  adhesions  (a  condition  al- 


368  THE  SURGERY  OF  THE  LUNGS 

most  universally  present).  Open  the  cavity  with  a  thrust  of 
the  finger,  and  drain  with  the  use  of  as  little  gauze  as  possible, 
unless  unusual  bleeding  should  occur.  Follow  the  same  princi- 
ples of  drainage  as  in  radical  operations  for  empyema. 

Lister  (1873)  added  much  to  encourage  the  opening  of 
lung  abscesses,  and  since  his  time  there  has  been  no  hesitation 
on  the  part  of  the  modern  surgeon  in  attacking  abscess  cavities 
of  the  lung,  as  evidenced  by  the  numerous  reports  that  have  ap- 
peared. Of  course  this  was  made  possible  by  Lister's  great 
discovery  of  the  antiseptic  treatment  of  wounds  and  incisions. 

In  the  Medical  Nczi's  (Vol.  LXXVIII,  No.  24).  Fowler  re- 
viewed forty-one  cases  of  decortication  of  the  lungs.  He 
favors  Estlander's  operation,  and  claims  that  decortication  is 
indicated  in  all  cases  of  empyema  not  complicated  with  tuber- 
culosis. Dunn,  however,  favors  the  Schede  method  of  opera- 
tion. He  says  that  although  tuberculosis  is  unfavorable  it  is 
by  no  means  always  so.  Bernays  claims  that  Hilton's  method 
of  dealing  with  abscess  cavities  in  the  lungs  gives  the  best  re- 
sults.    (American  Medicine,  June  22,  1901.) 

Borchert  operated  in  twenty-nine  cases  of  lung  disease,  in 
twenty-one  of  which  the  lung  itself  was  surgically  treated. 
This  writer  claims  that  operation  is  necessary  where  there  is 
danger  of  pyaemia,  septicaemia,  or  hjemorrhage.  He  says  surgi- 
cal interference  is  contraindicated  in  tuberculosis,  and  also 
makes  the  interesting  statement  that  no  case  of  tumor  of  the 
lung  has  been  diagnosticated  early  enough  for  operation.  He 
divides  his  operation  into  two  parts,  going  through  the  thorax 
and  pleura,  and  opening  the  lung  itself  (pneumonotomy).  He 
is  a  little  inconsistent,  in  that  he  claims  that  the  chest  should  be 
kept  closed  to  prevent  the  entrance  of  air,  and  then  states  that 
drainage  should  be  kept  up  for  some  time  after  the  operation. 

Trzebicki  (September,  1892)  reported  twelve  cases  ope- 
rated upon.  Three  were  not  complete  cures,  there  were  eight 
deaths,  the  result  not  known  in  three  cases,  and  one  case  was 
not  healed  when  the  report  was  made. 


ABSCESS — BRONCHIECTASIS  369 

Recovery  is  more  certain  in  acute  cases,  the  percentage  be- 
ing sixty-six.  Quoting  Trzebicki  again,  out  of  five  operations, 
involving  resection  of  lung  tissue,  there  was  one  complete  cure 
and  four  deaths.  He  reported  forty-two  cases  of  simple  ab- 
scess operated  upon.  Of  these  "  fourteen  were  reported  com- 
pletely cured,  in  three  cases  there  were  fistulse,  in  one  case  the 
result  was  not  known,  and  death  resulted  in  twenty-four 
cases."  He  also  gives  the  results  of  twenty-four  operations  on 
tuberculous  cavities,  reporting  five  complete  cures,  five  not 
healed,  nine  deaths  (one  of  these  three  years  after  operation), 
and  in  five  cases,  the  results  not  known. 

Quincke  tabulated  fifty-four  cases  of  abscess  of  the  lung, 
treated  surgically.  There  are  three  groups  in  his  classification, 
i.e.:  1st,  acute,  divided  into  simple  and  gangrenous;  2d, 
chronic;  3d,  suppurating,  by  foreign  body.  Eighty-three  per 
cent,  of  the  fifty-four  cases  were  in  the  lower  lobe.  He  reports 
twenty  deaths,  twenty  recoveries,  and  fourteen  cases  of  total 
failure,  or  imperfect  result. 

The  author  has  opened  the  chest  in  six  cases.  Three  were 
tuberculous  patients,  in  one  of  whom  the  right  lung  and  three 
months  later  the  left  lung  were  drained ;  death  ensued  four 
months  later.  All  died  within  six  months.  Of  three  trau- 
matic cases,  all  recovered. 

(See  chapters  on  Gunshot,  Lacerated  and  Incised  Wounds, 
Foreign  Bodies,  and  Abscess.) 


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•  i 


X  50. 

EcHiNOCOCCUs,  (Advanced  Stage), 


(Chapter  on  Animal  Parasites.) 


ABSCESS — BRONCHIECTASIS  371 

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96. 
Shurly,  Journal  American  Medical  Association,  1893,  XXI, 

297-301. 


372  THE  SURGERY  OF  THE  LUNGS 

HuBER,  Arch.  Pcediat.,  New  York,  1893,  X,  1007-11. 

VojE,  Medical  and  Surgical  Reporter,   Philadelphia,    1893, 

LXIX,  1009. 
Matignon,  Arch.  Gen.  Med.,  Paris,  1894,  I,  162-166. 
Leech,  Lancet,  London,  1894,  I,  87;  Intercol.  Quar.  Journal 

Medical  and  Surgical,  Melbourne,  1894,  I,  52-60. 
Rochester,  Medical  News,  Philadelphia,  1894,  LXIV,  61- 

64. 
Apolant,  Therap.  Monatsch.,  Berlin,  1894,  VIII,  455-457. 
Kauffmann,  Birmingham  Medical  Review,  1894,  XXXVI, 

222-4. 
Maragliano,  Bidl.  d.  Crin.,  Milano,  1894,  XI,  403-8. 
Breden,  Chir.  Vestnik,  St.  Petersburg,  1894,  X,  654-7. 
Krause,  Berlin.  Klin.  Wochenschr.,  1895,  347-9. 
Chadwick,  Phys.  and  Surg.,  Detroit,  1895,  XVII,  61. 
KuDiNTSEFF,  Vratch,  St.  Petersburg,  1895,  XVI,  784-6. 
Anderson,  Glasgow  Medical  Journal,  1895,  XLIII,  287-291. 
HiTziG,  Milnch.  Medicin.  Wochschr.,  1895,  813-815. 
Webb,  Lancet,  London,  1895,  I,  1640. 
RoDYS,  Medycyna,  1895,  XXIII,  901-5. 

Walton,  Belgique  Medical,  1895,  II,  545-552;  Medical  Jour- 
nal, 1897,  LXVI,  287-9. 
Matthew,  Medical  Reg.,  Richmond,  1897,  ^>  222-4. 
Reynaud,  Marseilles  Med.,  1897,  XXXIV,  581-586. 
Clark,  British  Medical  Journal,  London,  1897,  ^^y  800-802. 
Edwards,  Lancet,  London,  1897,  II,  1585. 
MiTTHEiL,  De  Med.  und  Chir.,  Bd.  I,  H.  L.,  also  Goidd's  Year- 

Book,  1897,  P-  115- 
Northrop,  Medical  and  Surgical  Report,  Presby.  Hasp.,  New 

York,  1897,  II.  83-89. 
Crespin,  Bull,  et  Mem.  Societe  Med.  d.  Hop.,  Paris,  1897,  XIV, 

734-736. 
Kijens  I,  Gaj^.  leg.  Warnaawa,  1897,  XVIII,  I,  32,  64,  102. 
Moore,  British  Medical  Journal,  London,  1897,  II,  342. 
SiCARD,  Bidl.  Societe  d' Anatomic,  Paris,  1897,  LXXII,  427- 

431- 


ABSCESS— BRONCHIECTASIS  373 

MoRELLi^  Morgagni,  Milano,  1898,  XI,  669-681. 
WiTHiNTON,   Boston  Medical  and  Surgical  Journal,    1898, 

CXXXVIII,  220-225  ;  Disc,  231-253. 
Burgess^  Lancet,  London,  1898,  I,  1054. 
KaRj  Indian  Medical  Record,  Calcutta,  3,  457. 
Halstead,  Detroit,  1898,  IV,  524-569. 
Mariani,  Rcviczv  d.  Med.  y  CJiir.  Prac,  Madrid,  1898,  XLIII, 

361-368. 
Glazebrook,  Nat.  Med.  Review,  Washington,  1898-99,  VIII, 

428. 
Alexseyeff,  Diesk.  Med.,  Moskau,  III,  405-408. 
Schmidt,  Z)(?w^.  Med.  Wochenschr.,  1898,  1503-45. 
HoBART,  Wien.  Klin.  Wochenschr.,  1898,  1083. 
Lewis,  Philadelphia  Medical  Journal,  1898,  II,  1368. 
GooDLEE,  British  Medical  Journal,  1899,  I,  133-7. 
Ktos,  Tidschr.  f.  d.  Morske,  Kristiana,  1899,  XIX,  15-23. 
Elsner,  Medical  Nezvs,  New  York,  1899,  XLIII,  150-165. 
Morton,  C.  A.,  British  Medical  Journal,  London,  1900;  I,  379- 

380. 
Cackovic,  Liecnciki  Viesnik.  Zagreb.,  1900,  XXII,  54. 
Jacobson,  O.,  Ztschr.  f.  klin.  Med.,  Berlin,  1900,  XL,  294-330. 
Parascandolo,  Gior.  Interna^,  di  Sc.  Med.,  Napoli,   1900, 

XXII,  529. 
Laub,    Allg.    Wien.    Med.    Ztg.,    1901,    XLVI,    326-328, 

338-339- 
ScHULZ,  J.,  Centralb.  f.  d.  Grenzgeh.  d.  Med.  u.  Chir.,  Jena, 

1901,  IV,  i-io,  65-71,  97-104,  145-158. 
Wills,  Le  Moyne,  Journal  American  Medical  Association, 

1901,  XXXVI,  19-22. 
Watkins-Pitchford,  W.,  British  Medical  Journal,  London, 

I  955-956. 
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888-889. 
Lange,  K.,  Hygeia,  Stockholm,  1902,  LXIV,  372. 
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XXXVII,  1 19-123. 


374  THE  SURGERY  OF  THE  LUNGS 

Putnam,  Medical  Nczvs,  New  York,  September  13,  1902. 

Schooler,  Iowa  Medical  Journal,  Des  Moines,  Iowa,  July  19, 
1902,  p.  370. 

Whitacre,  H.  J.,  Journal  of  the  American  Medical  Associa- 
tion, September  27,  1902. 


CHAPTER  IX 
GANGRENE 

Gangrene  of  the  lung,  while  not  infrequent,  has  been 
dealt  with  rather  mildly.  It  is  either  circumscribed  or  dif- 
fuse, and  has  a  downward  course  which  can  reasonably  be 
ascribed  to  the  course  of  the  lymphatics  of  the  lung  as  they 
terminate  in  the  bronchial  glands  at  its  root.  Perhaps  this 
downward  course  is  due  to  the  lessening  of  the  vitality  of 
the  pulmonary  tissue  as  the  extreme  border  of  the  apices 
is  approached. 

The  site  is  most  frequently  the  posterior  aspect  of  the 
upper  portion  of  the  lower  lobe.  Learee  says  gangrene  of  the 
lung  is  more  frequent  in  the  lower  than  in  the  upper  lobe. 
It  has  been  shown  that  women  have  gangrene  less  frequently 
than  men.  Its  bacillus  resembles  that  of  anthrax  (Pasteur 
and  Koch) ,  and  it  will  not  grow  unless  oxygen  (?)  is  excluded ; 
hence  its  favorite  location  is  within  the  chest.  Experiments 
have  shown  that  one  attack  gives  immunity,  and  that  the 
injection  of  toxines  will  also  immunize. 

Etiology. — The  causes  of  gangrene  are  numerous ;  such  as 
syphilis,  abscess  from  any  cause,  foreign  body,  and  the 
acute  inflammatory  diseases  of  the  respiratory  system.  It 
is  occasionally  the  result  of  the  pressure  of  aneurysmal,  or 
other  intrathoracic  tumors,  on  the  blood-vessels.  Fountain 
enumerated  among  the  causative  factors  traumatic  injuries, 
embolism,  and  immersion  of  the  body  in  cold  water.  Foun- 
tain's case  as  reported,  was  gangrene  of  the  lung  resulting 
from  a  foreign  body  lodged  in  the  right  bronchial  tube,  and 
terminating    in    emphysema,    and    perforation    through    the 

375 


376  THE  SURGERY  OF  THE  LUNGS 

diaphragm  into  the  colon.  Trauma,  infarct,  diabetes,  and, 
in  cases  of  dementia  and  epilepsy,  food  in  the  trachea,  are 
also  some  of  the  causes  of  gangrene  of  the  lung.  This  may 
explain  the  fact  that  the  statistics  of  Fischel  and  others  show 
that  gangrene  of  the  lungs  occurs  more  often  among  the 
insane. 

Historical  (i 858-1 903). — Martin  (1840)  reported  an  inter- 
esting case  of  abscess  of  the  peritonaeum  opening  into  the 
bronchi,  causing  gangrene  of  the  lung.  Fuller  (1859)  re- 
ported a  case  where  aneurysm  of  the  thoracic  aorta  had  pro- 
duced gangrene  of  the  upper  lobe  of  the  left  lung,  and  had 
terminated  by  bursting  through  the  pericardium.  Baretz 
(1874)  reports  a  case  of  gangrene  of  the  lung  from  consecu- 
tive embolism.  Magrath  (1880)  reported  a  case  of  gangrene 
of  the  right  lung  with  caries  of  the  spinal  column,  from  the 
passage  of  a  spear  of  grass  into  the  bronchus.  However, 
of  all  causes,  pneumonia  is  the  most  frequent. 

Holt  (1885)  had  a  case  of  a  child  three  years  old  in  which 
gangrene  of  the  lung  followed  an  attack  of  primary  pleuro- 
pneumonia. Andree  found  in  five  hundred  and  eighty-three 
autopsies  of  pneumonic  subjects  that  thirty-two  per  cent,  had 
gangrene.  Huss  found  but  twelve  per  cent,  in  two  thousand 
one  hundred  and  sixty-six  cases  of  pneumonia  in  men  from 
thirty-five  to  fifty-five  years  of  age. 

No  doubt  the  percentage  of  gangrenous  cases  in  pneu- 
monic conditions  is  greatly  increased  in  childhood  and  old 
age.  There  is  a  certain  percentage  of  lung  gangrene,  fol- 
lowing pneumonia  and  other  diseases,  which,  no  doubt,  re- 
cover by  the  formation  of  an  abscess,  and  drainage  in  the 
various  ways  the  abscess  develops. 

The  mortality  of  gangrene  of  the  lung  from  various  causes, 
if  let  alone,  is  probably  eighty-five  or  ninety  per  cent.,  while 
those  that  recover  by  operative  measures  are  tabulated  by 
True,  Hufinaker,  and  Heydweiller  (1879-92),  to  be  in  the 
proportion  of  thirty-six  recoveries  to  thirty-one  deaths. 


Plate  LIV. 


^v^-' 


X  30. 

ECHINOCOCCUS. 


X  9. 

Paragonimus  Westermani. 


(Chapter  on  Animal  Parasites.^ 


GANGRENE  377 

Many  interesting  facts  may  be  deduced  from  the  re- 
ports of  surgeons  in  regard  to  gangrene  of  the  lungs,  and 
notably  from  operations.  Guerin  (1830)  originated  a  per- 
cutaneous method  which  was  revived  by  Vidal  (1882). 
Breschet  (1831),  MacLeod  (1836),  Cleassens  (1839),  Hast- 
ings and  Stork  (1844),  Herff  (1844),  and  Collier  (1855), 
operated  evidently  for  empyema.  Finny  (1844)  operated  too 
late  for  gangrene  and  death  resulted.  Smith  (1883)  reports 
an  operation  for  gangrene,  while  Rose  (1884)  was  probably 
the  first  to  institute  extensive  surgical  measures  for  gangrene 
of  the  lung.  Smith  (1880)  had  previously  treated  pulmonary 
gangrene  by  incision.  White  and  also  Neisler  (1872)  opened 
a  tuberculous  cavity  of  the  lung.  Peterson  reports  a  case 
of  gangrene  of  the  lung,  with  rupture  of  the  eroded  vessels, 
and  sudden  death  from  haemorrhage  into  the  pleural  sac. 
Fenger  (1884)  wrote  on  the  surgical  treatment  of  gangrene 
of  the  lung,  in  a  report  which  is  of  much  value.  Cayley  and 
Gould's  case  of  gangrene  of  the  lung  (1883)  recovered.  Run- 
neberg  (1887)  operated  for  gangrene. 

Trzebicki  (September,  1892)  collected  twenty- four  cases 
operated  upon.  There  were  seven  complete  cures,  one  case 
of  fistula,  one  not  healed;  in  two  cases  the  results  were  not 
known;  thirteen  deaths  resulted. 

True  has  tabulated  most  of  the  cases  to  1885,  and  Paget 
from  1885  to  1895.  Simpson  (1890)  reported  four  cases  of 
haemorrhage  into  the  lung  tissue  with  oedema;  he  treated 
by  aspiration,  but  the  patient  died.  Anthony  had  a  case  re- 
quiring amputation  of  the  lung;  he  does  not  state  the  cause, 
but  it  is  probable  that  it  was  not  for  cancer.  Lebert,  Hutch- 
inson, and  Bonome  have  collected  the  cases  where  operations 
were  performed  for  gangrene  of  the  lung.  Out  of  seventy- 
one  cases  operated  upon,  fifty-four  died,  or  sixty-two  and 
a  half  per  cent. 

True  lost  six  out  of  thirteen;  Richevalle,  fourteen  out  of 
thirty-one;    Pabrecauts,    ten   out   of   twenty-six,    and    Paget, 


378  THE  SURGERY  OF  THE  LUNGS 

two  out  of  thirteen,  which  brings  the  mortahty  down  to 
thirty-nine  per  cent.  Thus,  it  is  shown  that  twenty-three 
per  cent,  more  recover  with  operation  than  without  it. 

From  reports  of  competent  surgeons,  it  is  probably  only 
traumatic  gangrene  that  offers  anything  to  surgery,  except 
drainage. 

McFarland  had  a  case  of  gangrene  of  the  lung  that  re- 
sulted fatally.  Hofmokl  (1889)  reported  a  case  of  lung  gan- 
grene. Kiemann  reported  a  case  of  induration  of  the  lung 
with  bronchiectasis.  Ross  (1889)  published  a  case  of  pneu- 
monomycosis  with  abscess  of  the  lung,  followed  by  gangrene. 
He  made  a  demonstration  of  fungus  and  bacteria.  Hisch- 
lerd  and  Terray  (1889)  reported  on  the  causes  of  gangrene 
of  the  lungs.  Girode  (1889)  had  a  case  of  gangrene  of  the 
superior  lobe  of  the  left  lung,  complicated  by  tuberculosis 
and  old  heart  troubles. 

Soupoult  (1889)  reported  a  very  interesting  case  of  a 
large  gangrenous  cavity  in  the  lung,  which  gave  all  the  signs 
of  pyopneumothorax  caused  by  a  suppurating  hydatid  cyst. 

Martin  (1890)  offered  suggestions  on  the  treatment  of 
pulmonary  gangrene,  and  Jaccoud,  Masci,  Standthartner,  and 
Ebstein  (1890),  have  reports  on  this  important  subject. 
Schrotter's  work  on  the  aetiology  of  pulmonary  gangrene,  etc., 
contains  valuable  hints.  Mader  also  has  some  ideas  as  to 
the  treatment  of  this  disease.  Laporte  had  a  case  of  pul- 
monary gangrene  in  a  man  who  was  a  porter,  in  which  the 
two  valves  of  the  pulmonary  artery  adhered. 

Bastianelli  (1889-90)  employed  pneumonotomy  in  treat- 
ing pulmonary  gangrene.  Hewelke  (1891)  too,  has  some 
useful  hints  on  lung  therapy.  O'Gorman  (1891)  reported 
his  notes  on  cases  of  circumscribed  pulmonary  gangrene  and 
fetid  bronchitis,  with  pathology  and  treatment.  Florschutz 
(1891)  showed  the  connection  between  pulmonary  gangrene 
and  diphtheria.  Bull  (1891)  reported  two  cases  of  gangrene 
of  the  lung,  operated  upon.     Thue  (1891)  also  reported  a 


GANGRENE  379 

case  of  gangrene  of  the  lung  operated  upon  with  subsequent 
death,  as  a  result  of  pericarditis.  Monsd  (1892)  described 
pneumonotomy  in  connection  with  a  case  of  gangrene.  Dunn 
(1892)  reported  a  case  of  softening  of  the  sensory  tract  of 
the  internal  capsule  with  lesion,  apparently  trophic,  on  opposite 
side  of  the  body;  death  ensued  from  gangrene  of  the  lungs 
and  pulmonary  haemorrhage. 

De  Ceronville  (1892)  published  his  observations  on  two 
cases,  in  which  he  resorted  to  pneumonotomy  for  gangrene 
of  the  lung.  Delageniere  employed  partial  pneumonotomy 
in  similar  cases,  and  Wells  also  reports  cases,  Streng  pub- 
lished a  paper  on  infusoria  in  the  sputum,  as  a  means  of 
diagnosis.  Lop  writes  on  the  aetiology  of  pulmonary  gan- 
grene, and  Moussons  on  its  surgical  treatment,  Fedotofif 
and  Simonin  each  add  to  the  number  of  cases  reported. 

Goelet  had  a  case  of  gangrene  of  the  lung  following  an 
attack  of  pleuro-pneumonia.  Reimbach  has  something  to 
say  about  etiology  of  lung  gangrene,  Hofmokl  (1895)  re- 
ported a  case  in  which  he  resorted  to  pneumonotomy,  with 
death  of  patient,     Mader  and  Parmerter  follow  with  reports. 

Babes  (1895)  published  his  "Pathogenesis  of  Pulmonary 
Gangrene,"  and  Mery  gave  the  results  of  his  bacteriological 
studies.  Alexsleyeff,  who  apparently  finds  so  much  fascina- 
tion in  the  study  of  the  lungs,  has  a  valuable  paper  also  on 
the  same  subject. 

Roscins  (Gould  and  Pyle's  "  Anomalies,"  et  caetera,  Phila- 
delphia, 1897)  is  said  to  have  removed  successfully  the  pro- 
truding and  gangrenous  portion  of  a  lung  which  extended 
through  a  penetrating  wound  of  the  chest  wall. 

Vekonet  (1897)  reported  a  case  of  lung  gangrene  surgi- 
cally treated.  Ewart  (1897)  has  a  paper  on  his  methods  of 
incision  and  drainage. 

Within  the  last  two  or  three  years  many  surgeons  have 
given  their  time  and  attention  to  the  treatment  of  gangrene 
of  the  lungs. 


380  THE  SURGERY  OF  THE  LUNGS 

The  greater  number  have  devoted  themselves  to  the 
surgery'  of  the  disease.  In  addition  to  those  already  referred 
to,  readers  interested  in  this  subject  might  profitably  con- 
sult Skeda,  Patton,  Rendu,  Zalenski,  ViUiere  (1898),  who 
advocate  surgical  intervention  in  treating  pulmonary  gan- 
grene. 

Besson  reports  a  death  from  haemoptysis.  Feme,  Swan, 
Bramwell,  Fussell,  and  Robertson  have  reported  cases.  Dere- 
reaux  (1899)  describes  his  method  of  treatment  with  creosote. 
Warrack  (1899)  reported  a  case  of  a  tooth  impacted  in  the 
left  bronchus,  causing  gangrene.  Pique  published  a  valua- 
ble paper  on  the  curable  forms  of  the  disease. 

H.  Lenhartz  reports  twenty-three  cases  of  gangrene  of 
the  lung,  treated  by  resection  of  ribs  and  pneumonotomy. 
There  has  been  complete  and  permanent  recovery  in  eleven; 
three  have  died  since  from  tuberculosis,  three  from  sepsis,  and 
one  from  general  debility.  Lenhartz  operated  in  two  sittings, 
as  it  is  impossible  to  suture  the  pleura,  and  union  has  to  be 
accomplished  by  vigorous  compression.  He  warns  against 
explorator}'  puncture,  as  it  entailed  empyema  in  at  least  one 
of  his  cases.  {Journal  American  Medical  Association, 
March  22,  1902,  p.  799,  Vol.  38,  No.  12.) 

Pathology — There  are  two  forms  of  pulmonary  gangrene, 
circumscribed  and  diffuse,  or  the  two  may  be  combined.  In 
the  circumscribed  the  area  is  first  brown  and  dry,  with  hurry- 
ing congestion,  and  blood  infiltration;  there  is  also  periodic 
or  constant  haemorrhage  from  eroded  vessels.  Extension 
of  the  process  is  probably  due  to  gravitation  of  fluid  into  the 
ends  of  the  bronchi,  combined  with  the  low  vascularity  of 
the  periphery  of  the  lung. 

Symptoms  and  Diagnosis. — The  chief  point  in  the  diagnosis 
of  pulmonary  gangrene  is  the  odor  of  the  sputum.  When 
placed  in  a  glass,  the  sputum  will  separate  into  three  layers. 
The  upper  layer  will  be  found  mucopurulent  and  frothy ;  the 
middle  greasy  and  watery ;  and  the  bottom  layer  will  con- 


Plate  LV. 


II' 


Paragoniimus  WESTEiniANi    (from   lungs  of  a  hog). 
I.    Section    Containing   the    Lung    Fluke   Cyst  Cut 
Open.      2.  Lung  Flukes,  Natural  Size.     3.  Con- 
tents of  Cyst   Containing    Eggs    of    Lung 
Fluke,   Greatly  Magnified. 


(Chapter  on  Animal  Parasites.) 


GANGRENE  381 

*sist  of  pus  and  yellow  shreds  of  tissue,  which,  with  the  peculiar 
fetid  odor,  is  diagnostic. 

Multiple  cavities  from  lung  abscess  or  gangrene  are  espe- 
cially hazardous.  The  temperature  may  be  above  (105°)  or 
below  the  normal  (97°).  The  pulse  is  rapid  and  feeble,  the 
skin  dusky.  There  are  prostration  and  an  anxious  expression ; 
there  is  dulness  upon  percussion  over  the  affected  side,  and  rales 
can  be  heard  in  the  otherwise  consolidated  lung.  The  respira- 
tory murmur  may  be  wanting,  and,  perhaps,  exaggerated 
resonance.  The  symptoms  in  fact  simulate  those  of  pneu- 
monia in  the  stage  of  consolidation.  Fragments  and  pus 
may  escape  through  the  bronchi  and  mouth.  In  addition 
to  the  high  fever,  prostration,  offensive  breath,  rusty  sputum, 
there  is  a  chill  at  onset,  adynamia,  dyspnoea,  cough  at  first,  more 
or  less  pain ;  the  temperature  is  subnormal  in  the  later  stages. 
The  expectoration  may  amount  to  twenty  ounces  in  twenty- 
four  hours,  and  its  marked  gangrenous  odor  is  characteristic 
and  never  to  be  mistaken.  Leyden  says  the  patient  reclines 
toward  the  affected  side. 

Treatment. — Open  chest  posteriorly  by  resecting  two  or 
more  ribs,  preferably  the  fifth  or  sixth,  or  both.  If  possible, 
operate  rapidly  with  a  local  anaesthetic.  Insert  a  finger  for 
exploration  and  evacuation  of  pus,  or  debris,  or  both.  Do 
not  pack  the  cavity  with  gauze,  unless  for  haemorrhage,  but 
keep  the  chest  wall  freely  open  for  drainage  and  irrigation. 
All  bleeding  vessels  in  the  thoracic  wall  must  be  occluded, 
as  the  severing  of  each  tissue  is  accompHshed. 

It  is  necessary  in  all  operations  for  gangrene  in  the  upper 
portion  of  the  lung  to  open  the  pleural  cavity  at  its  lowest 
point,  that  drainage  may  be  accomplished  by  gravity.  If 
possible,  the  gangrenous  portion  should  be  brought  out  of 
the  chest  opening.  If  the  entire  lobe  be  involved,  three 
ligatures  of  silk  or  kangaroo  tendon  should  be  used  to  transfix 
its  base,  one  to  surround  the  vessels,  one  the  bronchus,  and 
one  around  the  lung  tissue  proper.    This  once  accomplished. 


382  THE   SURGERY   OF   THE    LUNGS 

the  lobe  should  be  cut  away,  as  in  gangrene  or  any  other 
tissue. 

Complete  excision  and  drainage  are  the  two  great  princi- 
ples involved  in  operating  for  gangrene  of  the  lung.  Stimu- 
lation and  nourishment  should  receive  careful  attention. 
Much  of  the  operative  work  will,  no  doubt,  be  done  without 
general  anaesthesia.  The  surgeon's  finger  should  be  used 
instead  of  the  needle  or  knife.  None  of  the  important  blood- 
vessels will  be  severed,  and  none  of  the  bronchi  injured,  if 
the  finger  be  thrust  through  the  pleura  and  lung  tissue.  The 
sense  of  touch  will  enable  the  operator  to  locate  the  abscess 
with  greater  exactness.  The  finger  can  as  easily  detect 
pus  by  palpation  in  the  lung  as  in  any  other  soft  structure 
of  the  body. 

Garre  reports  one  hundred  and  twenty-two  cases  of  gan- 
grene of  the  lung  operated  upon,  with  sixty-six  per  cent, 
cured. 

August  3,  1903. 
Dear  Doctor  Ricketts:  In  June  I  operated  on  a  young 
lady  suffering  with  gangrene  of  the  lung.  Opening  was  made 
over  second  and  third  ribs,  anteriorly,  on  right  side  of  chest. 
Patient  died  on  the  operating  table  after  one  rib  had  been  re- 
moved. The  gangrene  followed  extraction  of  teeth — chloro- 
form and  ether  being  used — very  likely  followed  by  an  aspir- 
ation pneumonia.  Autopsy  showed  gangrenous  area  with 
abscess  directly  under  second,  third,  and  fourth  ribs. 

O.  A.  Blumenthal. 


GANGRENE  383 


BIBLIOGRAPHY 

Martin,  Medical  Examiner,  Philadelphia,  1840,  III,  349-352. 
Fountain,  North  Amer.  Med.-Chir.  Rev.,  Philadelphia,  1858, 

III,  854-862. 
Fuller,  Transactions  Path.  Soc,  London,  1859-60,  XI,  62- 

64. 
Learee,  Lancet,  London,  1871,  II,  47. 
Barety,  Compt.  Rend.  Soc.  de  Biol,  Paris,  1872  (1874-75), 

iv,pt.  2, 145-156. 

Magrath,  Lancet,  London,  1880,  I,  89. 

Rose,  International  Sc.  Rec,  New  York,  1880-81,  7. 

Smith,  Lancet,  London,  1880,  I,  86-88. 

Peterson,  Buffalo  Med.  and  Surg.  Journal,  1883-84,  XXIII, 

219. 
Fenger,  Transactions  Illinois  Med.  Soc,  Chicago,  1884,  III, 

62-68. 
Gould,  Med.-Chir.  Transactions,  London,  1884,  XLIV,  209- 

215. 
Holt,  Arch.  Pcediat.,  Philadelphia,  1885,  II,  88-95. 
Runneberg,  Deutsche  Arch,  fiir  Klin.  Med.,  1887,  Bd.  XLI, 

p.  91. 
McFarland,  Proc.  Path.  Soc,  Philadelphia,  1888-89,  II,  66. 
HoFMOKL,  Berlin  d.  k.  k.  Krankenaut  Riidolph-Siftung,  Wien 

(1888),  1889,  p.  350. 
Kiemann,  Berlin  d.  k.  k.  Krankenaut  Rudolph-Siftung,  Wien 

(1888),  1889,  pp.  355,  356. 
Ross,  Australia  Medical  Journal,  Melbourne,  1889,  n.s.,  3,  542- 

559- 
HiscHLERD  ET  Terray,  Croosi  hetil,  Budapest,  1889,  XXXIII, 

635-649- 
GiRODE,  Bidl.  Soc.  Anat.,  Paris,  1889,  LXIV,  3-6. 
SoupouLT,  Bull.  Soc.  Anat.,  Paris,  1889,  LXIV,  273-275. 
Martin,  Arch.  Med.  Beiges,  Bruxelles,  1890,  XXXII,  9-30. 
Jaccoud,  Ga::.  d.  Hop.,  Paris,  1890,  LXIII,  445-447. 


384  THE  SURGERY  OF  THE  LUNGS 

Masci,  Gas.  d.  Clin.,  Napoli,  1890, 1,  No.  14,  1-4. 
Standhartner,  Aerztl.  Berlin,  d.  k.  k.  Allg.  Krankh.  zur 

Wien  (1888),  1889,  p.  66. 
Ebstein,  Wien.  Klin.  Woch.,  Ill,  867-870. 
Mader^  Berlin  d.  k.  k.  Krankenast  Rudolph-Siftung,  Wien 

(1889),  1890,329-331. 
Laporte,  Echo  Medical,  Toulouse,  1891,  V,  377-379. 
Bastianelli,  Bull.  d.  Societa  Lancisiana  d.  Osp.  di  Roma, 

(1889-90),  i89i,X,  35-53. 
Hewelke,  Deut.  Med.   Wochenschr.,  Leipzig,    1891,    1130- 

1134- 
O'GoRMAN,  Med.  Press  and  Cir.,  London,  1891,  n.s.,  LIII,  673. 
Florschutz,  Corr.  Bl.  d.  Allg.  Aerzt.  v.  Thungen,  Weimars, 

1891,  LXX,  348-352. 
DuNN^  British  Medical  Journal,  London,  1892,  I,  1077. 
DeCeronville,  Rev.  de  Med.  de  la  Suisse  Rom.,  Geneve,  1892, 

XII,  229-235. 
Delageniere,  Cong.  Franc,  de  Chir.,  Proc.-Verh.,  etc.,  Paris, 

1892,  VI,  585-596. 

Wells,  New  York  Med.  Journal,  1892,  LVI,  199-208. 
Streng,  Fortsch.  d.  Med.,  Berlin,  1892,  757-763. 
Lop,  Gas.  d.  Hop.,  Paris,  1893,  LXVI,  249-256. 
MoussoNS,  Mem.  et  Bidl.   de  Med.   et  Chir.  de  Bordeaux, 

(1892),  1893,267-270. 
Fedotoff,  Objazat  pat.  Anat.  Izslied  ntud.  Med.  Imp.  Charkow 

Univ.,  1893,  II,  39-44- 
SiMONiN,  Rassegna  di  Med.  Moder.,  1893,  VIII,  499-506. 
Goelet,  North  Carolina  Medical  Journal,  Wilmington,  1894, 

XXXIV,  p.  217. 
Reimbach,  Centrhl.  f.  Allg.  Path.,  Jena,  1894,  V,  649-656. 
HoFMOKL,  Jahrb.  d.  Med.  k.  k.  Krankenart,  1895,  M.,  1897, 

IV,  pt.  II,  273. 
Mader,  Morbus  Addisonii,  Jahrb.  d.  Med.  K.  K.  Krankenart , 

1895,  M.,  1897,  IV,  pt.  II,  207. 
Parmerter,  Buifalo  Medical  Journal,  1895-96,  XXXV,  209- 

215- 


GANGRENE  385 

Babes,  Semaine  Med.  de  Paris,  1895,  XV,  538-540. 
Pique,  Ga^.  Med.  de  Paris,  1895,  9  s.,  33,  p.  411. 
Mery,  Bull.  Soc.  Anat.,  Paris,  1897,  LXXII,  225-230. 
Alexsleyeff,  Dictst.  Med.,  Moskowa,  1897,  ^I'  463- 
Vekonet,  Laitop  Russk.  Chir.,  St.  Petersburg,  1897,  II,  931- 

939- 
'Ev^ AWT,  Lancet,  London,  1897, 1,  1681. 

Dalziel,  Glasgow  Medical  Journal,  1897,  XLVIII,  211-213. 
ViLLiERE,  Paris,  1898. 

Patton,  Clinical  Reviezv,  Chicago,  1898-99,  IX,  165-169. 
Rendu,  Bidl.  et  Mem.  Soc.  d.  Hop.,  Paris,  1898,  XV,  498. 
Zaleski,  Ga^.  lek.,  Warszawa,  1898,  XVIII,  85-91. 
FussEL,  Transactions  Path.  Soc,  Philadelphia,  1898,  XVIII, 

85-91. 
Besson,  Journal  d.  Soc.  Med.  de  Lille,  1898,  II,  566. 
Fernet,  Bidl.  et  Mem.  Soc.  Med.  d.  Hop.,  Paris,  1899,  XVI, 

275-282. 
Swan,  Boston  Medical  and  Surgical  Journal,  1899,  CXL,  38. 
Bramwell,  British  Medical  Journal,  London,  1899,  I.,  70-75. 
Derereaux,  British  Medical  Journal,  London,  1899,  !>  532- 
Robertson,  British  Medical  Journal,  London,  I,  402. 
Warrack,  British  Medical  Journal,  London,  1899,  I,  401. 
Peyrot  et  Milian,  Presse  Med.,  Paris,  1900,  I,  201-202;  i 

trace. 
Lenhartz,  H.,  Mitteilungen  a.  d.  Grenzgehieten  (Jena),  IX, 

3- 
Garre,  Journal  American  Medical  Association,   March   22, 

1902,  p.  798. 
McArthur,  L.  L.,  Gangrene  of  Lung  Operation  Transactions 

Mississippi  Valley  Med.  Association,  1903. 


CHAPTER   X 
RUPTURE 

Authentic  reports  of  this  condition  began  with  Hick's 
case  of  a  child,  suffering  from  a  cough  resembHng  pertussis, 
whose  lung  ruptured  about  two  weeks  after  the  cough  began. 
Rupture,  without  injury  to  the  chest  wall,  has  been  reported, 
especially  by  Ashhurst.  This  condition  occurs  oftener  in 
children  than  in  adults,  and  if  death  results,  it  is  usually 
within  five  days.  There  may  be  laceration  of  the  lung  with- 
out blood-flow,  as  verified  by  a  specimen  in  St.  George's 
Hospital  Museum.  A  four-inch  laceration,  two  inches  deep, 
resulted  without  hemoptysis. 

The  mechanism  of  the  rupture  of  a  lung  without  fracture 
is  the  same  as  that  which  occurs  when  an  inflated  paper 
bag  is  struck  by  the  hand.  Gosselin's  explanation  is  that  it 
is  due  to  a  sudden  pressure  exerted  on  the  thoracic  wall,  at 
the  moment  of  full  inspiration,  concurrently  with  a  spasm  of 
the  glottis  or  obstruction  of  the  larynx.  Consequently  the 
lung  bursts.  Extravasation  of  air  takes  place,  resulting  in 
emphysema,  pneumothorax,  etc. 

Others  discard  this  theory  because  it  does  not  also  ex- 
plain cardiac  rupture  from  external  violence  on  the  thoracic 
walls.  They  claim  that  the  rupture  is  due  to  direct  pressure, 
as  in  the  case  of  heart  rupture  without  fracture  of  the  ribs. 
But  it  is  possible  that  the  rupture  of  a  small  bronchial  artery 
within  the  parenchyma  of  the  lung  may  be  the  occasion  of  a 
rupture  in  some  cases  where  there  has  been  no  external  injury 

to  the  chest  wall. 

386 


Plate   LVI. 


Lungs   of  a  hog-   showing   cysts  caused   by   Uuig   flukes 

(reduced)   from  i6th  Annual  Report  U.  S. 

Bureau  of  Animal  Industry. 


(Chapter  on  Animal  Parasites.) 


RUTTURE  387 

The  alveolar  tissue  being  so  fragile,  the  bursting  of  a 
very  small  artery  may  do  great  damage.  One  such  case  has 
come  under  the  author's  observation,  and  many  more  may 
have  occurred,  the  real  cause  being  overlooked. 

Ashhurst  collected  the  histories  of  thirty-nine  cases  of 
rupture  of  the  lung  without  fracture;  of  these  twelve  recov- 
ered. Otis  has  collected  reports  of  twenty-five  cases  of  this 
form  of  injury  from  military  practice  exclusively.  These  were 
generally  caused  by  a  blow  upon  the  chest  by  a  piece  of 
shell,  or  other  like  missile.  Among  the  twenty-five  cases 
there  were  eleven  recoveries. 

Historical  (1840-1903). — Tait,  of  Edinburgh  (1844),  was 
among  the  first  to  report  a  case  of  rupture  of  the  lung.  Bar- 
low (1844)  reported  a  case  of  hydropneumothorax  with  tuber- 
culous perforation.     Strong  (1850)  also  reported  a  case. 

Ferrari  (1855)  speaks  of  rupture  of  the  lung  by  deep 
inspiration;  DunHn  (1855)  reported  a  lesion  of  the  lung  caused 
by  compression.  Coulon  (i860)  reported  a  case  of  rupture 
of  the  lung  caused  by  the  passage  of  a  wagon-shaft  through 
the  chest.  Skay  had  a  case  without  external  injury.  Galvez 
(1864)  reported  a  case  from  violent  contusion  without  fracture 
of  the  ribs,  resulting  in  instant  death. 

Bermutz  (1865)  reported  a  case  of  rupture  following 
suppuration.  This  case  was  cured.  Ashhurst  (1871)  men- 
tions a  case  of  rupture,  without  injury  of  the  thoracic  parietes. 
Watson  (1881)  reported  a  case  of  laceration  of  the  lower  lobe 
of  the  right  lung  caused  by  violence  without  fracture  of  the 
ribs,  which  terminated  in  death.  Gould  (1882)  reported 
rupture  of  the  lung,  with  pneumothorax;  paracentesis  was 
performed,  followed  by  recovery. 

Gross  (1882,  Vol.  II,  p.  368)  says  that  rupture  of  the 
lung,  without  injury  to  the  thoracic  wall,  is  not  so  frequent 
as  at  one  time  supposed.  Laurent  (1883)  reported  a  rupture 
of  both  lungs,  with  external  injury,  followed  by  death.  Uck- 
niar  (1889-90,  and  1890-91)  published  his  contributions  on 


388  THE  SURGERY  OF  THE  LUNGS 

rupture  of  the  lung.  Buttell  (1892)  published  a  work  on 
the  general  treatment  of  lung  wounds.  Kerr  (1894)  reported 
a  case  of  rupture  of  the  lung,  associated  with  fracture  of  the 
ribs,  with  early  subsequent  recovery. 

De  Sanctis  (1894)  reported  his  method  of  suturing  in 
lung  rupture.  Comte  (1894)  published  his  notes  upon  a  case 
of  rupture  of  the  lung,  and  Hermanid  (1898)  reported  a  case 
of  rupture  from  whooping  cough. 

Wallingford  and  Roberts,  of  Paris,  Ky.,  were  called  to 
see  a  negro  who  had  died  suddenly.  He  was  a  stout,  robust 
fellow  with  a  good  history.  The  autopsy  revealed  nothing 
to  account  for  the  rupture  of  the  lung  except  that  one  of 
the  bronchial  arteries  had  ruptured.  The  rupture  of  the 
artery  was  doubtless  due  to  erosion  by  a  deposit  of  coal  dust, 
which  had  become  infected.    The  negro  was  a  coal-heaver. 

(For  Treatment  and  Symptoms,  see  Chapter  on  Lacerated 
and  Incised  Wounds.) 


BIBLIOGRAPHY 

Hicks,  London  Med.  Gaz.,  April  22,  1837,  119. 

Tait,  Jour.  Med.,  Edinburg,  1844,  I,  104-107. 

Barlow,  Lancet,  London,  1844,  I,  604. 

Strong,  Am.  Jour.  Med.  Sc,  Philadelphia,  1850,  XIX,  72. 

Ferrari,  1855,  Raccogliatore  Med.  di  Fauc,  2-2,  XI,  413-433. 

DuNiN,  Arch.  Path.,  etc.,  Verl,  1855,  CII,  323-345. 

CouLON,  Bull.  Soc.  de  Chir.,  Paris,  1860-61 — 62,  s.  i,  673-676. 

Skey,  Med.  Times  and  Gaz.,  London,  1862,  II,  59. 

Gould,  Lancet,  London,  1862,  I,  457. 

Galvez,  Aur.  Acad,  de  ciennied,  etc.,  la  Habana,  1864-65, 1,  28-30. 

Bermutz,  Jour,  de  Med.  et  Chir.  Prat.,  Paris,  1865,  2  s.,  VI,  405. 

AsHHURST,  1874,  Trans.  Path.  Soc,  Philadelphia,  1871-73,  IV. 

129-33- 
Watson,  Bull.  N.  Y.  Path.  Soc,  1881,  2  s.,  I,  228-230. 


Plate  LVII. 


Posterior  View  of   Heart  and  Lungs  of  Dog.    In- 
jected IN  Situ. 


(Description,  page  484.) 


RUTTURE  389 

UcKMAR,  Monitore  Med.  Morchigiano,  Loreto,  1889-90,  III,  fasc. 

II,  107-132. 
UcKMAR,  Gior.  Internaz.  d.  Soc.  Med.  Napoli,  1891,  n.  s.,  XIII, 

921-941. 
BuTTEL,  Halle  a  S.,  1892,  p.  40. 
Kerr,  Med.  News,  Philadelphia,  1894,  LXIV,  214. 
De  Sanctis,  Rijorma  Med.,  Napoli,  1894,  X,  pt.  I,  98-101. 
CoMTE,  Rev.  Med.  de  la  Suisse  Rom.,  Geneve,  1894,  XIV,  191-197. 
AsHHURST,  Int.  Clin.,  Philadelphia,  1894,  4  s.,  Ill,  151-161. 
Hermanid,  Tjdsch.  v.v.  Genessk.,  Amsterdam,  1898,  2  r.,  XXXIV, 

d.  2,  404-407. 
Wallingford  and  Roberts,  Cincinnati  Lancet  Clinic,  March 

9,  1901. 


CHAPTER  XI 
HERNIA 

Hernia,  or  pneumocele,  is  where  a  portion  of  the  lung 
protrudes  through  the  chest  wall,  or  below  the  clavicle,  or 
through  the  diaphragm.  In  most  definitions  of  hernia  of 
the  lung  it  is  stated  that  the  protrusion  of  the  lung  may 
be  through  the  chest  wall  or  through  the  diaphragm.  How- 
ever, although  many  cases  of  diaphragmatic  hernia  of  the  ab- 
dominal viscera  are  recorded,  there  is  but  one  instance  where 
the  lung  has  protruded  through  the  diaphragm.  When  it 
does  so  occur,  it  is  likely  to  be  on  the  left  side.  Out  of  two 
hundred  and  seventy-six  cases  of  hernia  of  the  abdominal 
viscera  through  the  diaphragm  reported  by  Lacher,  two  hun- 
dred and  twenty-five  were  on  the  left  side.  The  support 
afforded  by  the  liver  on  the  right  side  prevents  the  escape 
of  the  abdominal  viscera  into  the  thoracic  cavity. 

Hernia  of  the  lung  may  be  primary  or  secondary,  and  is 
usually  traumatic.  It  is  not  often  subcutaneous.  As  a  rule, 
a  slender  apex  enters  a  small  opening  in  the  chest  wall  or 
diaphragm.  The  protrusion  is  increased  by  inspiration  and 
decreased  by  expiration;  and,  if  not  immediately  returned  to 
the  pleural  cavity,  will  sooner  or  later  become  hard  and  dry. 

If  not  immediately  reduced,  the  adhesion  to  the  adjacent 
soft  tissues  will  be  so  firm  that  operative  measures  will  be 
necessary  to  release  it. 

Hernia  of  the  lung  is  to  be  differentiated  from  chronic 
abscess,  from  hernia  of  omentum,  intestines,  or  liver  upon 
the  right,  and  of  the  stomach  or  pericardium  upon  the  left. 

390 


HERNIA  391 

Hernia  is  generally  sudden,  but  may  be  gradual,  or  appear 
subsequently.  If  late,  it  may  be  free  from  adhesions,  and 
therefore  reducible.  It  is  more  frequently  in  the  right  lung, 
owing  to  the  latter  having  one  more  lobe  and  fissure.  It 
is  not  necessarily  fatal,  nor  does  it  shorten  life.  It  is  very 
rare,  and  may  vary  in  size  from  that  of  a  hazel-nut  to  that 
of  the  human  head. 

Operative  measures  should  not  be  resorted  to,  unless  gan- 
grene should  ensue.  It  is  indicated  if  the  tumefaction  be 
troublesome  by  giving  pain  or  by  undue  prominence.  The 
subcutaneous  form  of  hernia  of  the  lung  is  said  to  be  always 
reducible.  Some  teach  that  if  the  hernia  protrudes  externally 
through  the  cutaneous  structures,  reduction  must  be  attempted. 
If  this  fails,  or  if  gangrene  appears,  the  protruded  part  must 
be  removed,  or  allowed  to  slough  away. 

The  other  variety  of  hernia  of  the  lung  may  be  reduced 
and  held  in  place  by  pad  or  belt. 

Historical  (1499-1903). — Rolandus  (1499)  published  one 
of  the  first  reports  of  a  surgical  operation  for  hernia.  It  is 
worthy  of  reproduction. 

"  Called  to  a  citizen  of  Bologna  on  the  sixth  day  after 
wound,  I  found  portions  of  the  lung  issued  between  two 
ribs.  The  afflux  of  the  spirits  and  humors  had  deterrpined 
such  a  swelling  of  the  part  that  it  was  not  possible  to  reduce 
it.  The  compression  exercised  by  the  ribs  retained  its  nutri- 
ment from  it,  and  it  was  so  mortified  that  worms  had  de- 
veloped in  it. 

"  They  had  brought  together  the  most  skilled  Chirurgeons 
of  Bologna,  who,  judging  the  death  of  the  patient  to  be 
inevitable,  had  abandoned  him,  but  I  yielded  to  his  prayers 
and  those  of  his  parents  and  friends,  and,  having  obtained  leave 
from  the  Bishop,  the  Master,  and  the  man  himself,  I  yielded  to 
the  solicitations  of  about  thirty  of  my  pupils,  making  an 
incision  through  the  skin,  the  breadth  of  my  little  finger- 
nail, away  from  the  wound,  all  round  it,  then  with  a  cutting 


392  THE   SURGERY   OF   THE   LUNGS 

instrument  I  removed  all  the  portion  of  the  lung  level  with 
my  incision. 

"  The  wound  resulting  from  the  resection  was  closed  by 
the  issuing  from  my  incision.  By  the  grace  of  God  it  cicatrized 
and  recovery  took  place. 

"  It  is  true  that  one  had  to  wait  long  for  it. 

"  The  patient,  with  his  master,  Rolandini,  has  since  made 
a  voyage  to  Jerusalem,  returning  in  good  health. 

"  If  you  ask  me  what  I  should  have  done  in  this  case,  I 
answer:  I  should  have  dilated  the  wound  with  a  small  piece 
of  wood,  keeping  the  lung  warm  with  a  cock  or  fowl,  split 
down  the  back,  or  should  then  have  reduced  it  and  kept  the 
wound  open  until  the  portion  of  the  lung  was  wholly  mortified. 

"  If  you  still  question  me  to  know  how  this  man  can  live 
without  his  lung,  I  answer:  That  the  part  remaining  in  the 
chest  profits  by  the  nutriment  destined  for  the  whole  lung, 
and  so  is  developed.  Nature  has  been  able  to  create  supple- 
mentary parts  in  it,  which  is  an  easy  thing,  that  is  so  soft  and 
near  the  warmth  of  the  heart." 

Tulpius  (1674)  ligated  and  cut  off  three  ounces  of  a  herni- 
ated lung ;  the  patient  recovered.  Chassier  also  mentions  a  her- 
niated lung,  and  was  the  first  to  give  it  special  consideration. 
Erichson  reports  a  case  in  a  cornet  player.  Boerhave's  case 
(1814)  was  due  to  child-birth,  and  occurred  in  the  mother. 
Cloquet  ( 1819)  reports  a  case  in  a  man  thirty-two  years  of  age, 
who  was  crushed  under  a  gun-carriage,  but  recovered. 

Morell-Lavallee  collected  thirty-two  cases  of  hernia  of 
the  lung.  Forde  (1837)  reports  a  case  in  which  a  protruding 
portion  of  the  lung  was  removed.  Lake  (1852)  reported  a 
case  of  hernia  of  the  lung,  caused  by  the  handle  of  a  wheel- 
barrow penetrating  the  side  of  the  chest.  Dufour  (1855) 
reported  a  case  of  traumatic  hernia  cured  without  an  opera- 
tion, after  having  caused  much  loss  of  blood.  Hale  (1856) 
details  a  case  which  required  removal  of  a  part  of  the  left 
lung. 


HERNIA  393 

In  twenty  thousand  wounds  during  the  War  of  the  Re- 
belHon  there  were  only  seven  hernise  of  the  lung.  Cockle 
(1873)  published  a  case  of  double  pulmonary  hernia.  Lewtas, 
of  India  (1876),  reported  a  case  of  congenital  hernia.  From 
the  same  country  another  native  physician  (1878)  reported 
a  case  of  wound  in  the  chest  with  protrusion  of  lung,  and  death. 

H.  Hirschprung  (1879)  reported  a  case  of  congenital 
hernia  of  the  lung,  and  Beale  reported  an  equally  interest- 
ing case  of  hernia  through  the  diaphragm.  Hagentorn 
(1892)  speaks  of  a  case  of  pneumonotomy  in  pneumocele. 
Malpeli  (1892)  mentions  "  pneumonotomies."  Muller  (1893) 
resected  the  lung  with  gratifying  results.  Pitt's  lecture 
(Lancet,  October  14,  1893,  and  Transactions  Ninth  French 
Surgical  Association)  states  that  the  protrusion  occurs  at  once, 
or  at  any  time  later.  Lopez  (1894)  reported  a  resection  of  the 
lung  for  hernia,  with  recovery. 

The  year  1894  marks  an  epoch  in  Japanese  surgery,  and 
Karotta,  a  rising  young  surgeon  of  that  country,  excised 
a  herniated   lung  with  success. 

Omar  (1894),  of  Lyons,  made  a  total  extirpation  of  a 
lung.  Llobet,  Reclus,  and  TufHer  (1895)  all  mention  re- 
sections of  the  lung,  and  Knox  reported  two  cases  of  hernia 
of  the  lung  into  the  neck. 

From  1895  to  the  present  there  have  been  several  cases 
of  hernia  of  the  lung  and  its  treatment  reported  by  Nagy, 
Roussell,  Martiny,  von  Nagy,  Wightman,  Gaillard,  Vogeler, 
Rotenpeiler,  and  Potain, 

Reymei,  of  Paris  (1895),  reported  a  successful  operation 
for  traumatic  hernia  of  the  lung.  Convey  collected  four- 
teen cases  of  removal  of  portion  of  lung,  with  twelve  recov- 
eries. Heydweiller  says:  "  It  is  safe  to  remove  it,"  referring 
to  the  protruding  part  of  the  lung.  Vulpius,  of  Berlin  (1900), 
reported  a  case  of  hernia  of  the  lung  resulting  from  injury. 
Five  weeks  after  a  plastic  operation  the  patient  was  dis- 
charged, cured. 


394  THE  SURGERY  OF  THE  LUNGS 

Symptoms  and  Diagnosis. — These  are  very  definite.  The 
front  and  side  of  chest  and  the  lower  costal  spaces  are  more 
frequently  the  site.     Old  adhesions  prevent  hernia. 

Morell-Lavellee  and  Otis  maintain  that  the  hernia  is  not 
increased  on  inspiration  and  decreased  on  expiration.  Slow, 
natural  expiration  should  not  increase  the  tumefaction,  but 
it  is  far  different  when  expiration  is  violent. 

Paget  says  a  sudden  puncture  of  the  chest  is  followed 
by  immediate  expiration,  with  closed  or  half-closed  glottis, 
raising  the  pressure  in  both  lungs,  or  causing  overflow  of  air 
from  the  sound  into  the  injured  lung,  and  thus  the  hernia 
is  brought  about;  without  cough  or  violent  expiration  it 
could  not  occur. 

A  gradual  hernia  may  have  a  true  sac  lined  with  pleura, 
free  from  adhesions,  and  reducible.  Protrusion  is  always 
accompanied  by  vesicular  murmur  and  a  crackling  sound. 

There  are  many  successful  reductions  reported.  The  only 
certain  relief  is  to  remove  the  ribs  and  return  the  protruding 
parts. 

Treatment. — The  removal  of  a  section  of  one  or  more 
ribs  should  be  avoided  if  possible.  The  protrusion  of  the 
lung,  as  a  rule,  is  through  the  intercostal  space,  but  occa- 
sionally it  will  protrude  through  an  opening  in  the  chest- 
wall,  as  a  result  of  displaced  fracture  of  the  rib. 

If  the  herniated  sac  is  lined  with  pleura,  reduction  is 
usually  very  easily  accomplished.  If  not,  great  difficulty  is 
encountered.  In  either  event,  reduction  may  be  impossible. 
If  reduction  can  be  accomplished  by  manipulation,  the  open- 
ing can  easily  be  closed  perfectly  and  permanently  by  incorpo- 
rating in  the  sutures  periosteum,  or  ribs,  or  fragments  there- 
from. 

If  the  sac  is  lined  with  pleura,  and  reduction  cannot  be 
done  by  manipulation,  sections  of  ribs  should  be  made.  After 
the  lung  has  been  returned  to  the  pleural  cavity  the  opening 
should  be  closed  in  a  similar  manner.     That  is,  by  suturing 


Plate  LVIIl. 


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HERNIA  395 

the  periosteum,  or  ribs,  firmly  together,  dividing  them  if 
necessary  (osteoplasty). 

If  there  is  no  pleural  membrane  incorporated  within  the 
hernial  tissue,  and  the  hernia  can  be  returned  to  the  pleural 
cavity,  the  opening  in  the  chest  is  to  be  closed  as  directed 
above;  but  if  it  cannot  be  returned  to  the  pleural  cavity  by 
manipulation,  and  the  protrusion  is  through  the  intercostal 
space,  amputation  of  the  projecting  mass  is  the  only  resource 
left. 

This  should  be  done  only  after  transfixing  it  with  a  liga- 
ture, to  prevent  haemorrhage,  and  the  integumentary  tissue, 
together  with  the  periosteum,  if  possible,  should  be  subse- 
quently sutured  over  it. 


BIBLIOGRAPHY 

BoERHAVE,  Bull,  de  la  Fac.  de  Med.,  Paris,  1814,  IV,  p.  50. 
Chassier,  Bull,  de  la  Fac.  de  Med.,  Paris,  1814-15,  IV,  50-54. 
Morell-Lavallee,  Traite  des  Mai.  Chirurgie,  1824,  VII,  266. 
FoRDE,  Med.-Chir.  Transactions,  London,  1836,  XX,  pp.  378-381. 
Lake,  Dublin  Quart.  Journal  Medical  Science,  1852,  XIII,  231-233. 
Hale,  Transactions  Medical  Sciences,  Philadelphia,  1855,  V,  40. 
DuFOUR,  Compt.  Rend.  Societe  de  Biologic  (1854),  Paris,  1855, 

2  s.,  I,  pt.,  2,  15-24. 
Cockle,  Medical  Times  and  Gazette,  London,  1873,  I,  5-31. 
Lewtas,  Indian  Medical  Gazette,  Calcutta,  1876,  XI,  212. 
LiUGH,  Indian  Medical  Gazette,  Calcutta,  1877,  XII,  245. 
HiRSCHPRUNG,  Hasp.  Tid.  Kjobent.,  1879,  2  r.,  II,  953-959. 
Beale,  Lancet,  London,  1882,  I,  139. 
Reymer,  Medical  Week,  Paris,  1895,  III,  537. 
RoussEL,  Arch,  de  Med.  et  Pharm.  Mil,  Paris,  1895,  XXVI,  61-69. 
QuENU,  Gazette  Med.,  Paris,  1895. 
Nagy,  Orvosi  hetil.,  Budapest,  1896,  XI,  29. 
Martin Y,  Bull.  Acad.  Med.,  Paris,  1897,  XXXVIII,  140. 
VP.N  JSTagy,  Centrbl.  }.  d.  Therap. 


396  THE  SURGERY  OF  THE  LUNGS 

Gailliard,  Bull,  el  Mem.  Societe  Med.  Hop.,  Paris,  1897,  XIV. 

946. 
WiGHTMAN,  British  Medical  Journal,  London,  1898,  I,  365. 
VoGLER,  Monatschr.  /.  Unjalheilk.,  1898,  V.  169-176. 
RoTHEMPiELER,  Wien.  Med.  BlalL,  1898,  XXI,  pp.  471-473. 
PoTAiN,  Semaine  Med.,  Paris,  1898,  Vol.  XVIII. 
VuLPius,  Berliner  Klinische  Woch.,  den  Dec.  No.  50,  XXXVII, 

Jahrganz,  pp.  11 52-1 154;  i  fig. 


CHAPTER  XII 
CEDEMA 

QEdema  is  the  effusion  of  serum,  from  many  causes,  into 
the  submucous  connective  tissue.  Flint  says  the  transudation 
is  primarily  within  the  air-cells,  the  serum  also  infiltrating 
the  interlobular  structure.  It  may  be  slow  or  rapid,  and  is 
produced  by  several  conditions,  principally  by  acute  and  in- 
fectious diseases.  The  malignant  form  is  due  to  a  specific 
germ. 

Valvular  disease  of  the  heart  is  a  prominent  factor  in  its 
causation.  Compression  of  the  lung  by  a  tumor  of  any  char- 
acter, inhalation  of  hot  or  cold  air,  or  gases,  suppurative 
hepatitis,  Hodgkin's  disease,  eclampsia,  leucaemia,  anaemia, 
or  chlorosis,  may  cause  it.  It  may  be  local  or  general,  and 
is  usually  found  in  persons  under  fifteen  years  of  age.  It 
is  indicated  by  dyspnoea,  varying  in  intensity. 

Historical  (i 891-1903). — Muller  (1891)  describes  this  con- 
dition in  a  most  interesting  manner,  while  von  Basch  reports 
a  series  of  experiments  to  show  its  pathology.  Anthony 
(1891)  speaks  of  a  case  of  pulmonary  oedema,  secondary  to 
nephritis,  complicating  pregnancy.  Smith  (1891)  reports  a 
case,  while  Grossmann  (1891)  verified  the  work  of  Basch  by 
his  experimental  research.  Ferri  (1893)  reports  a  case  of 
pulmonary  oedema  after  the  publication  of  one  by  von  Ziesell 
(1893).  Lowith  (1893)  also  mentions  an  interesting  case. 
Corin  (1897)  mentions  a  case  of  pulmonary  oedema,  while 
Milian  (1897)  speaks  of  pulmonary  sclerosis,  and  Flava  (1897) 
mentions  kaolinosis. 

397 


398  THE  SURGERY  OF  THE  LUNGS 

Freyberger  (1897)  speaks  of  an  anaemic  infarct  in  the  lung. 
Furinami  (1898)  also  speaks  of  a  haemorrhagic  infarct  into 
the  lung,  which  caused  pulmonary  oedema.  Paulain,  Natale, 
and  Fouineau  (1898)  each  make  mention  of  cases.  Fouineau 
(1898),  in  a  most  interesting  article,  mentions  the  rarity  of 
pulmonary  oedema. 

Momburi  reported  a  case  of  pulmonary  apoplexy  and 
thrombosis.  Muller  showed  by  his  experiments  that  if  the 
vagi  be  divided  in  the  neck,  death  will  result  from  the  in- 
filtration of  the  lungs  and  air-passages  with  serum.  Hasse 
remarked  a  peculiar  fact  in  cases  of  general  dropsy  which 
prove  fatal,  viz.,  that  one  lung  is  always  found  adherent  to 
the  pleura,  and  the  other  is  not.  The  adherent  lung  is  oede- 
matous,  and  the  other  is  compressed  by  hydrothorax. 

Symptoms  and  Diagnosis. — There  is  increased  frequency 
of  respiration  with  dyspnoea,  and  dulness  on  percussion.  The 
respiratory  murmur  is  lost,  or  very  feeble.  The  vocal  reso- 
nance may  be  increased.  The  presence  of  liquid  is  denoted 
by  fine  mucous  or  subcrepitant  rales.  The  pulse  is  rapid  and 
feeble.  When  the  efYusion  involves  the  interstitial  tissue, 
cyanosis  appears,  and  there  is  often  intense  suffering. 

The  sputum  increases  with  the  increase  of  serum  in  the 
alveoli.  It  is  often  thin  and  watery,  and  sometimes  viscid. 
In  this  case  it  increases  the  dyspnoea  by  obstructing  the 
larynx.  It  is  at  times  tinged  by  the  presence  of  red  blood- 
corpuscles.     Urea  may  also  be  found  in  the  sputum. 

There  is  no  fever  unless  there  are  complications.  In  ex- 
treme cases  the  patient  dies  from  heart  failure  and  carbonic- 
acid  poisoning.  Bianci's  phonendoscope  is  claimed  to  be  a 
useful  instrument  in  tracing  the  progress  of  the  oedema. 
CEdema  may  be  differentiated  from  bronchopneumonia  by 
the  physical  signs,  which  in  the  latter  disease  show  no  marked 
difference  between  the  affected  and  the  non-affected  areas. 
The  mucous  rales  occur  late  in  the  bronchopneumonia,  while 
they  are  present  from  the  begiiming  in  oedema. 


Plate  LIX. 


1-n 

00 


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a 


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(EDEMA  399 

Hydrothorax,  too,  possesses  some  things  in  common  with 
oedema,  but  in  hydrothorax  change  of  position  of  patient  will 
alter  the  area  of  dulness. 

Treatment. — Measures  are  to  be  directed  to  the  causative 
diseases.  At  the  same  time,  use  every  means  to  sustain  the 
heart's  action.  Phlebotomy  has  been  advocated,  and  Hu- 
chard  says  that  the  best  treatment  for  the  acute  form  is 
venesection  from  the  arm. 

(See  also  Treatment,  in  the  Chapter  on  Gangrene  and 
Abscess.) 

Apply  the  same  surgical  measures  as  used  in  abscess  and 
gangrene  of  the  lung,  and  in  addition,  employ  the  syphilitic 
remedies.  Abscess  and  gangrene  of  the  lung  caused  by 
syphilis  cannot  be  differentiated  from  pulmonary  abscess  and 
gangrene  from  other  causes.  Not  all  cases  of  abscess  or  gan- 
grene of  the  lung  in  a  syphilitic  patient  are  due  to  syphilis, 
for  these  diseases  may  exist  as  complications  of  syphihs. 
Whether  the  cause  of  the  abscess  or  gangrene  is  syphihs  or 
not,  it  should  be  treated  as  if  it  were. 

Abscess,  gangrene,  and  syphilis  of  the  lung  present  nearly 
the  same  physical  signs.  Often  it  is  only  by  the  closest 
study  and  a  full  knowledge  of  the  patient's  history  that  any- 
thing like  a  satisfactory  diagnosis  can  be  made.  Foetor  of 
the  breath  is  common  to  all  three.  In  gangrene  the  foetor 
is  intensely  foul  and  persistent.  In  abscess  there  is  foetor, 
but  it  is  not  excessive,  nor  does  it  have  the  peculiar  gan- 
grenous odor.  Pulmonary  abscess  must  not  only  be  differ- 
entiated from  gangrene,  but  also  from  putrid  bronchitis.  In 
the  latter  disease,  the  odor  of  the  breath  resembles  acacia 
blossoms. 

Gangrene  is  also  to  be  distinguished  from  putrid  bronchi- 
tis. In  this  last  disease  the  sputum  does  not  contain  shreds 
of  lung  tissue,  nor  is  there  the  fatal  marasmus  that  accom- 
panies gangrene. 

It  should  also  be  remembered  that  oedema  may  result 


400  THE  SURGERY  OF  THE  LUNGS 

from  either  of  these  diseases,  or  from  the  maladies  which 
gave  rise  to  them.  In  oedema  the  sputum  is  of  diagnostic 
importance.  At  times  it  is  thin  and  watery,  and  again  viscid. 
It  may  at  times  be  colored,  and  in  this  case  the  color  is  due 
to  the  presence  of  red  blood-corpuscles.  It  may  also  con- 
tain urea.  But  when  the  sputum  splits  up  in  the  three  char- 
acteristic layers,  as  described  in  the  chapter  on  Gangrene, 
there  can  be  no  mistake,  and  whatever  else  may  be  found 
on  thorough  examination,  you  may  rest  assured  that  you 
have  a  case  of  pulmonary  gangrene. 

CEdema  is  to  be  carefully  differentiated  from  broncho- 
pneumonia. Rales  are  present  from  the  beginning  in  oedema, 
but  not  until  rather  late  do  they  appear  in  bronchopneumonia. 

Hydrothorax  is  easily  distinguished  from  oedema,  because 
change  of  position  produces  an  alteration  in  the  area  of 
dulness. 

In  all  the  diseases  considered  here,  temperature  is  not 
a  positive  diagnostic  factor.  It  may  be  present  or  it  may 
be  absent.     It  is,  usually,  a  sign  of  infection  when  it  does  exist. 

Surgical  treatment  is  essentially  the  same  for  all  three 
diseases.  Nothing  should  be  done  rashly.  Make  sure  of 
your  diagnosis,  and  then  operate   boldly. 

BIBLIOGRAPHY 

KovACS,  Wien.  Klin.  Woch.,  1891,  41-45. 

MuLLER,  Corr.  Bl.  f.  Schw.  Aerzie,  Berlin,  1891,  XXI,  432-438. 

VON  Basch,  Bd.  Beitrage  zur  Pathologie  des  kneislaufe  lungen- 

oeden  cardiaie.     Berlin,  1891,  221  p. 
Anthony,  Boston  Medical  and  Surgical  Journal,  1891,  CXXXV, 

468. 
Smith,  Med.  Rec,  New  York,  1891,  XL,  730. 
Grossmann,  Ztschr.  }.  Klin.  Med.,  Berlin,  1892,  XX,  397-406. 
Ferri,  Rassegna  Med.,  Bologna,  1893,  I,  No.  6. 
von  Zeisell,  Centrlhl.  }.  Phys.  Leipzig  u.  Wien,  1893-94,  VII,  702. 


cedema  401 

LowiTH,  Beitrage  zu  Path.  Anat.  u.  Allg.  Path.,  Jena,  1893,  XIV, 

401-442. 
CoRiN,  Slalper,  Li^ge,  1897-98,  I,  277. 
MiLiAN,  Bull.  Anat.  Soc.j  Paris,  1897,  LXXII,  496-516. 
Flava,  Wien.  Klin.  Rundschau,  1897,  XI,  609. 
Freyberger,  Trans.  Path.  Soc,  London,  1897-98,  27-30. 
FuRiNAMi,  Arch.  /.  Path.  Anat.,  1898,  CLIII,  61-193. 
Paulain,  Presse  Med.,  Paris,  1898,  II,  362. 

Natale,  Gior.  Internaz.  d.  Med.  Soc,  Napoli,  1898,  XX,  988-992. 
FouiNEAU  (Raoul),  Paris,  1898,  268,  No.  133;  Medical  News, 

1898,  LXXIII,  714-716. 
MoMBURi,  Courier  Medical,  Paris,  1899,  LIX,  2-4. 


CHAPTER  XIII 
POLYPI    IN    THE    BRONCHIA 

Only  a  few  cases  of  polypi  of  the  bronchia  have  been 
reported.  Many  cases  have  been  overlooked  or  else  have 
not  been  clearly  diagnosticated.  Polypi  may  degenerate,  or 
slough,  and  be  coughed  up  and  expectorated,  and  thus  escape 
detection.  No  doubt,  many  obscure  cases  of  pulmonary  dis- 
ease are  due  to  polypi  in  the  bronchia.  There  are  several 
reports  of  fibrous  growths  in  the  bronchia.  Cases  of  this 
character  are,  perhaps,  many  times  due  to  polypi  which  have 
degenerated.  The  same  is  also  true  of  hyperplasi^e.  So,  too, 
many  cases  of  haemoptysis  that  have  appeared  inexplicable 
may  have  been  caused  by  polypi.  The  titles  of  many  papers 
indicarte  that  their  authors  were  not  sure  of  their  diagnosis. 

It  is  very  probable  that  polypi  of  the  bronchia  are  not 
so  exceedingly  rare  as  some  writers  assume.  Just  what  effect 
polypi  in  the  bronchia  have  on  the  lungs  is  unknown.  Polypi 
in  the  lungs  themselves  have  been  reported  by  some  ob- 
servers. 

In  case  of  a  very  large  polypus  in  the  bronchia  there  is 
danger  of  the  bronchia  being  occluded.  If  it  be  one  of  the 
ultimate  bronchia,  the  result  may  not  be  very  serious,  but 
in  case  of  the  larger  many  grave  complications  may  arise; 
not  only  from  the  occlusion  of  the  bronchia,  but  the  increase 
in  growth  of  the  polypi,  will  cause  a  dilatation. 

The  excessive  dilatation  of  the  larger  bronchia  exerts 
great  pressure  on  the  neighboring  tissue  of  the  lung.  There 
results  from  this,  not  only  a  loss  of  lung  capacity,  but  the 

402 


Plate  LX. 


00 


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o 

D 


POLYPI    IN   THE   BRONCHIA  403 

blood  supply  is  shut  off,  and  this  portion  of  the  lung  may 
become  gangrenous  or  atrophied.  Abscesses  may  also  re- 
sult from  polypi  in  the  bronchia. 

If  a  polypus  becomes  degenerated,  or  is  torn  loose  by 
the  movements  of  the  lungs  in  efforts  to  expel  it,  the  lungs 
may  become  infected. 

The  mere  presence  of  polypi  in  the  bronchia  does  no 
harm,  but  the  increase  in  size  of  the  polypi  may  cause  gan- 
grene, by  constriction  of  the  blood-vessels. 

Historical  (1700-1903). — Clark  (1700)  reported  a  case  of 
polypus  of  the  lungs,  and  Bussiere  reported  a  similar  case. 

Samber  (1719)  reported  a  case  of  polypus  which  was 
coughed  up  from  the  windpipe.  Nichols  had  a  somewhat 
similar  case  in  which  the  expectorated  polypus  resembled  a 
branch  of  the  pulmonary  vein.  Strack  (1799)  published  a 
work  on  "  Polypi  as  a  Causative  Factor  in  Pulmonary  Dis- 
eases." Acharius  (1802)  wrote  a  paper  on  a  case  of  pul- 
monary polypus.  Cheyne  (1808)  had  a  case  of  bronchial  poly- 
pus. Hankel  reported  several  cases  of  chronic  tracheitis  and 
bronchitis  due  to  polypi. 

Middlendorff  (1837)  published  a  dissertation  on  polypi  of 
the  bronchia.  North  (1838)  gave  an  account  of  two  cases  of 
bronchial  polypus.  Berliner  (1848)  published  a  work  on 
polypi  of  the  bronchia.  Oppolzer  (1858)  had  a  case  of  chronic 
tracheitis  and  bronchitis  due  to  polypi.  Morris  (1862)  re- 
ported several  cases  of  bronchial  polypus.  Commandre  ( 1872) 
observed  polypi  form  masses  in  the  bronchia.  Warren  (1876) 
published  a  paper  on  the  nature,  etc.,  of  bronchial  polypi. 

Symptoms. — The  symptoms  of  polypi  in  the  bronchia  are 
very  similar  to  those  caused  by  the  benign  tumors.  If  the  poly- 
pus has  a  pedicle,  there  will  be  a  noticeable  change  in  the  bron- 
chial sounds.  This  will  be  caused  by  the  polypus  swinging 
back  and  forth,  but  when  the  growth  of  the  polypus  produces 
occlusion  of  the  bronchia,  the  sounds  will  cease. 

Hearn  and  Roe  {American  Magazine,  July  1901)  reported 


404  THE   SURGERY   OF   THE   LUNGS 

a  case  of  pneumonotomy  for  abscess  of  the  lung,  due  to  a  poly- 
pus. Two  operations  were  performed ;  on  making  an  exami- 
nation of  the  abscess  cavity,  after  the  second  operation,  a  poly- 
pus was  found  extending  into  the  abscess  cavity.  These 
writers  believe  that  localized  gangrene  was  responsible  for  the 
trouble.  They  claim  that  the  abscess  cavity  was  not  a  saccular 
bronchiectatic  cavity;  but  it  is  very  probable  that  the  polypus 
observed  after  the  second  operation,  was  the  prime  cause  of  the 
abscess.  It  is  not  likely  that  a  polypus,  several  centimeters  in 
length  would  have  developed  in  the  interval,  between  the  two 
operations.  Nothing  is  said  to  indicate  that  the  polypus  had 
been  seen  before  the  examination  of  the  cavity. 

This  case  illustrates  the  importance  of  a  thorough  knowl- 
edge of  the  condition  of  the  lesion  in  all  pulmonary  troubles. 
This  is  necessary,  not  only  for  diagnostic  purposes,  but  that  the 
proper  surgical  procedure  may  be  selected. 


CHAPTER    XIV 
ATELECTASIS   APNEUMOTOSIS 

Atelectasis  pulmonum  (imperfect  expansion  of  the 
lungs)  is  a  condition  more  often  spoken  of  in  literature  than 
found  in  actual  practice.  Atelectasis,  collapse,  or  carnification 
is  rare  and  always  congenital.  When  caused  by  continued 
compression  of  the  lung  by  fluid,  new  growth,  gauze  packing, 
or  compression  from  any  cause  after  birth,  it  is  termed  apneu- 
motosis. 

"  Congenital  atelectasis  is  of  great  medico-legal  import. 
This  much  has  been  demonstrated,  notwithstanding  the  contro- 
versies which  have  arisen  among  pathologists:  i.  That  atelec- 
tasis may  continue  indefinitely  as  a  foetal  condition,  and  occur 
in  infants  who  have  lived,  breathed  and  even  cried.  2.  The 
presence  of  much  pigment  shows  that  the  affection  has  not  de- 
veloped before  the  fifth  year.  3.  The  absence  of  pigment  does 
not  necessarily  show  a  foetal  condition,  because  the  pigment 
may  have  been  absorbed  in  the  process  of  time.  4.  Complete 
absence  of  air  from  the  alveoli  is  an  evidence  of  death  before 
birth.  5.  Aspirated  products  found  in  the  air  passages  is  abso- 
lute evidence  of  respiration  "  (Abrams). 

Mechanism  of  Collapse. — Lichtheim  demonstrated  that  in 
bronchial  obstruction,  the  air  is  absorbed  by  the  vessels  of  the 
alveolar  walls,  aided  by  the  inherent  lung  elasticity.  The  oxy- 
gen is  most,  and  the  nitrogen  least  rapidly  absorbed.  Obstruc- 
tion collapse  may  occur  in  any  part  of  the  lung,  but  the  site  of 
predilection  is  the  lower  lobes.  Here,  many  factors  are  in- 
volved in  explanation  of  this  fact.     Insomuch  as  bronchitis  is 

405 


406  THE  SURGERY  OF  THE  LUNGS 

a  common  cause  of  obstruction,  the  secretions  gravitate  to  the 
most  dependent  parts.  Again,  the  lower  chest  is  more  phant 
and  mobile,  and  is,  therefore,  very  susceptible  to  external  atmos- 
pheric pressure. 

Complications. — "  i.  The  atelectatic  areas  may  pass  into  a 
condition  of  fibroid  induration.  2.  Dilatation  and  hypertrophy 
of  the  right  heart  are  present,  due  to  causes  which  will  be  dis- 
cussed in  the  next  chapter,  on  emphysema.  3.  Thrombosis  is 
present  in  the  brain  sinuses,  due  in  part  to  the  imperfect  circula- 
tion, and  in  part  to  the  debilitated  condition  of  the  system.  4. 
There  is  compensatory  emphysema,  the  healthy  lung  assuming 
the  functions  of  the  collapsed  areas.  5.  There  is  persistence 
of  the  foramen  ovale  and  ductus  arteriosus.  These  channels 
are  closed  normally  within  two  weeks  after  birth,  but  they  may 
remain  patent,  owing  to  the  enfeebled  respiration  which  causes 
the  blood  to  linger  in  the  right  heart,  and  to  utilize  the  foetal 
channels  for  voiding  its  contents  "  (Abrams). 

Historical  (1832-1903). — Joerg  (1832)  reported  a  case  of 
morbid  pulmonary  organ,  and  imperfect  respiration  from  birth. 
G.  H.  Barlow  (1841)  published  his  observations  on  certain  dis- 
eases originating  in  early  youth,  illustrating  his  position  by 
three  cases  of  defective  expansion  of  the  lungs.  Spangenburg 
(1844)  had  a  case  of  atelectasis  with  uterine  respiration. 
Fischer  ( 1851 )  reported  a  case  of  infantile  atelectasis  pulmonis. 

In  1852,  appeared  Meig's  paper  on  atelectasis  pulmonum 
and  collapse  of  the  lung  in  children,  with  cases.  Cockle  ( 1856) 
reported  a  case  of  acquired  atelectasis  (carnification)  of  the  en- 
tire upper  lobe  of  the  right  lung,  from  direct  mechanical  press- 
ure. Ward  (1856)  reported  a  case  of  enlarged  thymus,  and 
atelectasis,  in  an  infant  which  survived  its  birth  four  hours. 

Kunkler's  work  throws  some  light  on  this  questionable  con- 
dition. His  work  prepared  the  way  for  Hewitt's  discoveries 
concerning  apneumotosis  or  pulmonary  collapse,  and  observa- 
tions on  the  diagnosis  and  treatment  of  such  cases.  Clark 
(1859)  reported  a  case  of  carnification  of  the  lungs  in  an  in- 


ATELECTASIS   ATNEUMOTOSIS  407 

fant.  Thomas  (1864)  had  a  case  of  complete  atelectasis  of  the 
lungs.  Houston  (1867)  reported  a  case  of  congenital  atelec- 
tasis, with  death  after  the  establishment  of  respiration. 

Stevens  gave  an  account  of  two  cases  of  collapse  of  an  en- 
tire lobe  of  the  lung,  without  displacement  of  the  thoracic 
viscera.  Long  reported  a  case  of  pulmonary  collapse  caused  by 
hnsmoptysis.  T.  Barlow  (1879-80)  reported  an  interesting 
case  of  atelecstasis  of  the  lungs,  emphysematous  cysts,  and  con- 
genital heart  disease.  Meigs  (1879)  reported  a  case  of  col- 
lapse of  the  lung,  and  cyanosis  in  a  young  infant,  produced  by 
violent  crying.  Francke  (1883)  also  reported  cases  of  atelec- 
tasis. Owen  (1886)  tells  of  a  case  of  complete  collapse  of  both 
lungs,  without  organic  disease  or  mechanical  injury. 

Adams  published  in  1898  an  article  on  postnatal  atelectasis. 
The  Italians  have  been  especially  interested  in  this  subject.  At 
Kiel  (1891)  appeared  an  article  on  a  case  of  atelectasis  compli- 
cated by  bronchiectasis.  Werner  also  published  an' account  of 
a  somewhat  similar  case.  Abrams  (1894)  published  his  obser- 
vations on  the  pathology  of  pulmonary  atelectasis.  Desplats 
(1894)  had  a  case  of  gastrointestinal  apneumotosis,  which 
caused  atelectasis  of  the  two  lower  lobes  of  the  lung,  and  death 
by  asphyxiation. 

Patton's  work  on  bronchiectasis  (1898-99)  with  those  of 
Whitney,  Starr,  and  Case,  and  their  reports  of  one-sided  chron- 
ic pulmonary  atelectasis,  brings  the  published  knowledge  up  to 
date. 

Symptoms  and  Diagnosis. — It  is  only  when  the  atelectasis  is 
extensive  that  the  condition  in  the  infant  is  recognized,  small 
foci  giving  rise  to  no  demonstrable  manifestations.  Cough  and 
fever  are  absent  as  a  rule.  Cyanosis  is  usually  marked  and  pro- 
gressive, and  corresponds  to  the  impaired  respiratory  move- 
ments and  imperfect  chest  expansion.  The  cyanosis  is  specially 
prominent  in  the  face  and  fingers.  The  pulse  is  feeble,  rapid, 
and  irregular. 

Physical  examination  of  the  chest  shows  recession  of  the 


408  THE  SURGERY  OF  THE  LUNGS 

lower  thorax  with  each  inspiration.  If  the  child  cries  during 
the  examination,  it  does  so  with  difficulty,  and  the  cry  is  no 
more  than  a  moan. 

Percussion  shows  dulness,  usually  marked  in  the  infero- 
posterior  portions  of  the  lungs.  The  percussion  below  must  be 
light,  otherwise  one  only  obtains  impaired  resonance.  If  the 
hand  of  an  assistant  is  made  firmly  to  compress  the  thorax 
above  the  area  percussed,  any  dulness,  if  present,  is  accentu- 
ated; the  compressing  hand  confines,  as  it  were,  the  thoracic 
vibration,  and  prevents  its  transmission  to  the  percussional 
area. 

Auscultation  is  by  no  means  conclusive.  The  respiratory 
murmur,  although  usually  absent  or  enfeebled  over  the  atelec- 
tatic area,  may  be  intensified  to  bronchial  breathing. 

Pathology — A  part  or  all  of  the  lung  may  be  involved  in 
either  atelectasis  or  apneumotosis. 

The  tissue  is  non-crepitant,  smooth,  dark  blue,  or  purple  in 
color;  becoming  hard  and  dense  with  age  of  the  child,  if  not 
aerated  soon  after  birth.  Bronchitis  is  the  most  common 
cause. 

Paralysis  of  the  pneumogastric  nerve  as  the  result  of  press- 
ure from  tumor,  injuries,  or  otherwise,  is  also  a  causative 
factor.    "  The  dyspnoea  is  of  the  inspiratory  type  "  (Abrams). 

Treatment — "  Place  in  fresh  air,  induce  vomiting,  and  try 
artificial  respiration,  remove  mucus  from  mouth  and  throat, 
with  gauze  or  finger.  Induce  cutaneous  stimulation  by  alter- 
nating hot  and  cold  water ;  try  rectal  divulsion  with  finger  and 
rhythmical  contraction  of  the  tongue  "    (Laborde). 

Mouth  to  mouth  inflation  of  the  lungs,  with  tongue  of  pa- 
tient drawn  forward  and  his  nostrils  closed,  is  a  useful  proced- 
ure.    Emetics  should  not  be  given,  as  they  are  useless. 


Plate  LXI 


A. 


B. 

Transverse  Sections  of  the  Heart  and  Lungs. 
(Description,  page  485.) 


ATELECTASIS   APNEUMOTOSIS  4O9 


BIBLIOGRAPHY 

JoERG,  Dublin  Journal  Med.  and  Chem.  Society,  1834,  V,  36-41. 

Barlow,  Guy's  Hospital  Reports,  London,  1841,  VI,  235-264. 

Fischer,  Berlin,  1841. 

Spangenburg,  Marburg,  1844. 

Meigs,  American  Journal  of  Medicine,  Philadelphia,  1852,  n.  s.. 

XXIII,  83-102. 
Cockle,  Association  Medical  Journal,  London,  1856,  II,  loio. 
Ward,  Pathologic  Society,  London,  1858,  VIII,  99. 
KuNKLER,  Louisville  Review,  1858,  494-501. 
Clark,  Lancet,  London,  1859,  I,  p.  92. 
Thomas,  Nederl.  Tijdschr.  van  Geneesk.,  Amsterdam,  1864,  III, 

337- 
Houston,  Leavenworth  Medical  Herald,  1867-68,  I,  p.  303. 
Stevens,  Medical  Association,  St.  Louis,  1870,  V,  35-38. 
Hewitt,  Lancet,  London,  I,  625,  1857;  and  Reynolds'  System  of 

Med.,  Vol.  Ill,  p.  862-882,  187 1. 
Long,  Lancet,  London,  1875,  II,  49. 

Barlow,  Transactions  Pathologic  Society,  London,  1870-89. 
Meigs,    American    Journal    Obstet.,    New    York,    1879,    XII, 

68-81. 
Francke,    Deut.    Arch.    Klin.   Medicin.,    Leipzig,    1883,    LIII, 

125-143- 
Owen,  American  Lancet,  Detroit,  1886,  X,  pp.  205-7. 

Adams,  American  Text-book,  Dis.  of  Child. 

Tanessia  (Sunto),  Attir.  ist.  Veneto  di  sc.  lettedarti,  1889,  VII, 

I 303-1 306. 
Berlin,  Kiel,  1891,  14. 
Werner,  Dresden,  1891,  p.  36. 
Abrams,  Med.  Rec,  New  York,  1894,  XL VI,  269. 
Desplats,  Journal  de  Science  Med.  de  Lille,  1894,  I,  545-553. 
Gallet,  Clinic,  Brussels,  1894,  VIII,  609-616. 
Whitney,  Boston  Medical  and  Surgical  Journal,  1898,  CXXXIX, 

616-619. 


4IO  THE  SURGERY  OF  THE  LUNGS 

Starr,  Philadelphia,  1898,  2d  pp.  899-903.     (Diseases  of  Child.) 
Patton,  Clinical  Review,  Chicago,  1898-99,  VIII,  219-223. 
Case,  Lancet,  London,  1899,  I,  m;  "  Hertz's  Handbuch,"  edited 

by  Ziemssen,  Volume  V,  p.  418. 
Abrams,  a.,  The  Medical  Fortnightly,  March  10,  1903,  pp.  193- 

201. 


CHAPTER    XV 
SYPHILIS 

Syphilis  being  next  to  tuberculosis  in  importance  as  a 
causative  factor  in  lung  abscess  and  gangrene,  should  be  con- 
sidered. Unlike  their  action  in  tuberculosis,  remedial  agents 
for  syphilis  will  prevent,  at  least  to  a  very  great  degree,  the 
formation  of  lung  abscess  and  gangrene,  if  they  will  not  at  all 
times  cure  them.  There  are,  perhaps,  no  pathologic  lesions 
more  easily  influenced  or  completely  overcome  by  medicaments 
than  those  caused  by  syphilis.  It  is,  therefore,  proper  to  use 
the  remedies  for  syphilis  to  the  maximum  degree,  not  only 
before  abscess,  or  gangrene,  or  both,  manifest  themselves,  but 
during  their  existence,  and  after  any  operative  measure  that 
may  have  been  employed. 

Not  all  cases  of  lung  syphilis  terminate  in  abscess  or  gan- 
grene. Such  conditions  are  indeed  few,  in  comparison  with 
those  of  syphilitic  tubercle,  that  are  not  arrested  in  their  course, 
and  overcome  by  proper  medication  before  such  a  destructive 
stage  is  reached. 

Historical  (1797-1903). — The  literature  of  this  subject  be- 
gins with  the  publication  by  Zadig  in  1797,  of  a  paper  on  dis- 
eases of  the  lungs  from  venereal  sources.  Then  nothing  ap- 
peared until  1 84 1.  That  year  Munk  published  his  paper  on 
syphilitic  diseases  of  the  lungs.  Ten  years  elapsed  before  any- 
thing else  on  this  subject  was  published. 

Lagnean  (1853)  published  his  work  on  the  diseases  of  the 
lungs,  caused,  and  influenced  by  syphilis.  Stevenart  (1853) 
announced  the  fact,  that  constitutional  syphilis  often  revealed 

411 


412  THE  SURGERY  OF  THE  LUNGS 

itself  by  grave  changes  in  the  lungs,  etc.  Aitken  ( 1863)  pub- 
lished his  notice  of  pulmonary  lesion,  associated  with  syphilis. 
Fontain  (1865)  observed  a  case  of  syphilis  of  the  lung,  in  an 
eight  months  foetus.  Mescrede  (1866)  published  a  paper  on 
the  subject.  Gintrac  (1867)  had  a  case  of  syphilitic  phthisis. 
Negri  (1868)  published  his  paper  on  Some  Practical  Consider- 
ations concerning  Syphilitic  Diseases  of  the  Lungs. 

Dr.  Lindseth  (1870)  appeared  with  his  work  on  syphilitic 
phthisis,  laryngitis,  etc.  He  boldly  advocated  certain  ideas, 
which,  at  the  time,  caused  considerable  criticism.  Ouvre  was 
the  most  important  of  his  critics.  Depaul  (1870)  reported  a 
case  of  syphilitic  alterations  of  the  lung  at  birth.  We  are  also 
indebted  to  Fox  for  additional  knowledge  of  syphilitic  affection 
of  the  lung. 

Zelinski  (1871-72)  issued  a  paper  on  inflammation  of  the 
pleura  in  a  syphilitic  patient.  Hand  (1872)  reported  an  inter- 
esting case  of  syphilis,  accompanied  by  capillary  bronchitis,  and 
lobular  solidification  of  the  lung  tissue.  Huchard  ( 1873)  pub- 
lished his  work  on  syphilitic  tumors  of  the  lungs.  Goodhart 
(1873)  also  reported  cases  of  syphilis  of  the  lungs.  Grandi- 
dier  (1875)  published  a  valuable  paper  on  the  same  subject. 
Rollitt  (1875)  made  a  contribution  to  the  literature  of  this 
subject.  Fournier  (1875)  also  published  a  report.  His,  how- 
ever, was  more  of  a  treatise  on  syphilitic  phthisis. 

Pentinalli  (1877)  published  a  valuable  paper  on  congenital 
and  acquired  syphilitic  diseases  of  the  lungs.  Frey  (1876)  re- 
ported a  case  of  infiltration  of  the  lung  from  syphilis.  Ma- 
homed ( 1876-77)  published  two  cases  of  syphilitic  disease  and 
early  fibroid  of  the  lung.  Gowers  reported  cases  that  came 
under  his  observation. 

De  Bomilla  (1876-77)  reported  a  case  of  tracheobronchial 
adenoid,  due  to  syphilis.  Porter  also  reported  a  case  of 
syphilitic  phthisis,  and  Poggio  the  same  year  reported  a  case 
somewhat  similar.  Tiffany  has  a  valuable  paper  on  syphilitic 
diseases  of  the  lungs.     We  are  under  obligations  again  to 


Pi-ate   LXII. 


1  RANsx'ERsi':  Sections  of  tiie  Luxgs. 
(Description,  page  486.) 


SYPHILIS  413 

an  Italian,  for  Jaunuzzi's  paper  on  hereditary  and  acquired 
syphilitic  diseases  of  the  lungs. 

Landrieux  (1878)  published  a  useful  work  covering  all  the 
syphilitic  diseases  of  the  lungs.  Raindohr  ( 1878)  added  much 
in  the  way  of  caring  for  these  diseases  by  his  work  on  methods 
of  treatment.  Vierling  (1878)  had  a  case  of  syphilis  of  the 
trachea  and  bronchia.  Kortmann  (1878)  published  an  exten- 
sive treatise  on  syphilitic  diseases  of  the  lungs.  Bresse  ( 1879) 
published  his  study  on  a  case  of  syphilitic  phthisis  in  an  adult. 
Proksch  (1879)  pubHshed  his  history  of  syphilis  of  the  lungs; 
Warder  reported  a  case  of  syphilitic  disease  of  the  pleura. 
Langehaus  also  reported  a  case;  Eve  and  Schnitzler  (1879) 
had  several  valuable  reports  on  syphilitic  diseases  of  the  lungs. 

Sacharjiss  (1879)  contributed  valuable  lessons  in  his  work 
on  the  diagnosis  of  syphilitic  pneumonia.  Henop  (1879)  also 
published  a  report  on  syphilis  of  the  lungs. 

Cantarano  (1880)  furnished  contributions  to  the  clinical 
history  of  these  diseases.  Frank  (1880)  had  a  valuable  paper 
on  syphilis  of  the  lungs,  and  discussed  the  relation  of  such  dis- 
eases to  hereditary  syphilis.  Gamberini  (1880)  made  some 
excellent  clinical  studies  in  syphilitic  diseases  of  the  lungs. 
Von  Cube's  report  contains  a  great  deal  of  new  matter. 

Lehmann  (1881)  had  an  interesting  paper  on  the  same 
subject.  Sailer  ( 1881 )  reported  two  cases  of  pulmonary  syph- 
ilis. Rutgers  von  den  Loef  reported  several  interesting  cases. 
Schech  (1881)  made  the  literature  interesting  by  his  reports. 
Pancritius  ( 1881 )  published  his  work  on  the  practical  treatment 
of  syphilitic  diseases  of  the  lungs.  Engstrom,  too,  has  practi- 
cal and  useful  hints  on  the  treatment  of  syphilis  of  the  lung. 
Schech  (1882)  published  a  paper  on  syphilis  of  the  lung  and 
trachea.  Rodriguez  Gongora  (1882)  reported  on  methods  of 
treatment.  The  year  1882  was  prolific  in  papers  and  reports  on 
this  subject.  Carlier's  study  upon  pulmonary  syphilis;  Con- 
cetti's  case ;  and  Hiller's  two  cases,  are  all  important  contribu- 
tions.    Engel  (1882)  was  the  first  to  differentiate  pulmonary 


414  THE  SURGERY  OF  THE  LUNGS 

syphilis  from  tuberculous  phthisis,  or  rather,  to  give  a  method 
of  differential  diagnosis  in  cases  of  syphilitic  diseases  of  the 
lung.  He  also  has  some  valuable  remarks  upon  the  pathology 
of  the  lungs  in  this  disease.  Guntz  (1882)  published  a  valu- 
able paper  on  diagnosis  by  examination  of  the  sputum. 

The  next  year,  1883,  is  also  prolific  in  reports,  papers,  etc., 
on  this  subject.  Raphael.  Senger,  Blondeau,  De  Renzi,  and 
Nogueire  each  have  published  cases  that  came  under  their  ob- 
servation. 

Rethi  (1884)  reported  methods  of  treatment.  Koeniger, 
Kopp,  De  Renzi,  Hiller,  and  Juarez  with  his  paper  on  lung 
troubles  in  children,  caused  by  syphilis,  made  lasting  contribu- 
tions to  medical  literature  upon  this  subject. 

The  year  1885  was  not  the  least  prolific  in  papers  and  re- 
ports on  lung  syphilis,  as  witness :  Porter,  Signorini,  Ferguson, 
and  the  valuable  article  in  the  Boston  Medical  and  Surgical 
Journal.  Wt  are  again  placed  under  obligation  to  Schnitzler 
for  his  paper  on  the  pathology  of  pulmonary  syphilis,  etc.  Both 
Bruen's  remarks  and  Augier's  and  Laveran's  papers  are  valu- 
able. 

Szohner's  paper  (1886)  on  syphilitic  cirrhosis  of  the  lung 
and  mode  of  treatment  was  valuable.  Heler  (1886-87)  pub- 
lished papers  on  this  subject. 

Karnbach  (1887)  appeared  with  a  valuable  work  on  the 
pathology  of  syphilis  of  the  lung. 

Mauriac  (1888)  reported  a  case  of  tertiary  syphilis  of  the 
lung,  and  Ruhemann  added  to  our  knowledge  of  the  treatment 
of  this  class  of  disease.  Beissel's  paper  ( 1886)  also  proved  of 
value  because  he  details  his  experience  in  diagnosticating  cases 
of  syphilis  of  the  lung.  Potain's  work  on  the  history,  cause, 
pathological  anatomy,  symptoms,  and  diagnosis  of  pulmonary 
syphilis  is  of  great  value. 

De  Blois  (1889)  published  an  interesting  paper  on  the 
manifestations  of  syphilis  of  the  upper  air  passages.  Haslund 
( 1890)  reported  cases  of  a  similar  character.  Raymond  (  1890) 


SYPHILIS  415 

wrote  a  most  interesting  work  on  the  results  of  experiments  on 
animals,  regarding  tertiary  syphilis,  and  its  effects  on  the 
lungs,  larynx,  trachea,  and  bronchus;  also  bronchopneumonia, 
and  adenopathic  pleurisy;  the  peritracheal  compression  of  the 
right  recurrent  nerve,  and  miliary  aneurysm,  due  to  syphilis. 

Bokenko  (1890)  reported  a  case  in  which  the  left  lung  was 
affected,  and  at  the  same  time  the  patient  had  an  attack  of  ca- 
tarrhal pneumonia  of  the  right  lung.  Kurn  (1890)  reported 
a  case  of  pulmonary  syphilis. 

Forget  (1890)  reported  a  case,  complicated  with  adeno- 
pathic tracheobronchitis.  Lancereaux  (1891)  published  a 
work  on  the  various  pathological  changes  produced  in  the  lung 
by  syphilis.  Councilman  (1891)  and  De  Renzi  reported  cases 
of  pulmonary  syphilis.  Perry  (1890-91)  reported  a  case  of 
diffuse  syphilitic  fibroma  of  the  lung.  Neeman  reported  a  case 
of  multiple  gummata,  and  Rolleston  (1890-91)  reported  a 
similar  case. 

Satterthwaite  (1891)  published  a  treatise  on  pulmonary 
syphilis  in  the  adult.  Sevestre  (1891)  had  a  case  of  pneumo- 
thorax in  an  infant,  twenty-two  months  old,  due,  probably,  to 
syphilis,  and  Roublefif  added  his  contribution  to  the  study  of 
syphilitic  affections  of  the  lungs. 

Manfan  (1892)  reported  cases  and  De  Renzi  (1892)  pub- 
lished a  most  interesting  case  of  pulmonary  syphilis.  Seibert 
(1892)  brought  out  a  paper  on  syphilitic  bronchiostenosis  in 
children. 

Hodenpyl's  article  on  the  differential  diagnosis  of  miliary 
tuberculosis  and  gummata  in  the  same  lung,  is  of  great  value, 
and  Juleos's  work  on  the  diagnosis  and  treatment  of  pulmonary 
syphilis  is  also  timely  and  valuable.  Abrams  (1893)  reported 
the  results  of  an  autopsy,  held  in  a  case  of  death  from  syphilis 
of  the  lung.  Feulard  had  a  case  of  syphilis,  and  gummata  of 
the  right  lung  simulating  gangrene  and  tuberculosis.  His 
treatment  is  of  great  interest.  Peterson  and  Thompson  ( 1893) 
reported  cases  which  they  had  treated.     Bryson  published  a 


4l6  THE  SURGERY  OF  THE  LUNGS 

paper  on  some  of  the  manifestations  of  syphilis  of  the  upper  air 
passages. 

Schirren  and  Gerber's  reports  (1894)  were  on  cases  of 
hereditary  syphiHs  of  the  lungs.  Gemmell  had  a  very  interest- 
ing case  of  syphilitic  ulceration  of  the  trachea  and  bronchia, 
with  fibroid  induration  of  caseous  tuberculous  nodules  in  the 
basal  parts  of  the  lungs,  with  enlargement  of  the  lymphatic 
glands  and  gummata  in  the  liver.  Those  interested  in  this  sub- 
ject will  find  many  useful  hints  in  Le  Fevre's  work  on  the  value 
of  early  diagnosis  in  syphilitic  lesions  of  the  upper  respiratory 
tract. 

Straight  (1894)  had  a  case  of  pulmonary  syphilis,  compli- 
cated with  catarrh  of  the  apex.  Pispoli  ( 1895)  reported  a  very 
interesting  case.  Merigot  de  Treigny  (1896)  published  a 
valuable  paper  on  pulmonary  syphilis,  and  Tandoff's  paper  on 
the  same  subject  is  of  some  value.  The  same  may  be  said  of 
Vires's  paper.  Schwyzer  has  some  useful  and  valuable  data 
on  the  treatment,  especially  the  surgical  treatment,  of  cases  of 
syphilis  of  the  lungs.  Lucidi  has  made  a  contribution  to  the 
literature  on  this  subject. 

Potain's  paper  on  the  connection  of  alcoholism  and  pul- 
monary syphilis  is  of  great  value,  while  Mongour's  case  has 
some  points  worth  considering.  Taube  (1897)  writes  on  the 
treatment  and  Carruccio  (1897)  reported  cases  of  pulmonary 
syphilis.  Dinkier  (1898)  published  a  paper  on  the  manifesta- 
tion of  syphilis  in  the  upper  respiratory  tract,  with  a  report  of 
a  case  of  chancre  of  the  nasal  saiptum.  Dieulafoy  ( 1898)  pub- 
lished a  paper  on  syphilis  of  the  pleura,  lungs  and  bronchia. 
Fowler  (1898)  published  an  interesting  work  on  syphilitic  dis- 
eases of  the  lungs. 

At  the  Ninth  German  Medical  Congress,  April,  1901, 
Hausemann  exhibited  three  cases  of  syphilis  of  the  lungs.  He 
spoke  of  the  difficulty  of  differentiating  syphilis  of  the  lungs 
from  tuberculosis. 


Plate  LXIII. 


Posterior  View  of  Transverse  Section  of  the  Lungs. 
(Description,  page  486.) 


SYPHILIS  417 


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Plate  LXIV. 


Experiment  ox  Luxgs,  Xo.  4,  page  487. 


SYPHILIS  421 

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CHAPTER    XVI 

BENIGN    TUMORS— LYMPHOMA,    CHONDROMA, 
OSTEOMA,    DERMOID   TUMORS 

It  has  been  thought  best  to  make  but  three  divisions  in  the 
classification  of  tumors,  i.e.,  Benign  Tumors,  MaHgnant 
Tumors,  and  Parasitic  Tumors. 

Historical — Virchow  (1863)  was  the  first  to  make  a  satis- 
factory classification  of  tumors,  in  recognizing  a  homology  and 
a  heterology  in  new  growths,  even  though  a  homologous  growth 
may  become  heterologous. 

It  has  been  only  in  the  last  decade  that  certain  forms  of  be- 
nign tumors  have  been  observed.  Schultz  {Russk.  Med.,  St. 
Peter sb.,  1890,  xvi.,  518-524)  reports  a  case  of  primary  fibroma 
in  the  lung  of  a  child  two  years  of  age.  Moskowitz  (Gyn- 
ogyszat,  Budapest,  1891,  xxxi,  317-329)  had  a  case  of  scle- 
roma of  the  air  passages.  Poor  (Lond.  Lancet,  1895,  ^'  ^7Z) 
reported  a  case  of  tumor  of  the  lung;  while  ZakiefT  (Roussky 
Vratch,  St.  Peters.,  1897,  xviii.,  340-342)  reported  four  cases 
of  tumor  of  the  lung.  West.  (St.  Barth.  Hosp.  Reports,  1897, 
Lond.,  1898,  xxxiii.,  109-137)  reported  cases  of  new  growths 
of  lung  and  pleura. 

LYMPHOMA — Lymphoma,  pseudoleucsemia,  or  Hodgkin's 
disease,  is  a  rare  malignant  growth,  resembling  sarcoma,  that 
sometimes  attacks  the  lungs.  It  is  generally  secondary  to  pri- 
mary involvement  in  the  cervical  glands,  that  is,  other  than 
bronchial  glands  are  involved.  It  usually  follows  the  glands  of 
the  bronchia,  and  fills  the  lungs  from  their  base  by  involving 
the  interlobular  saepta.     It  is  a  formation  of  lymph  tissue  as  a 

422 


LYMniOMA — CHONDROMA,  OSTEOMA,  DERMOID  TUMORS     423 

diffused  infiltration  of  lung  tissue,  and  should,  therefore,  be 
classed  with  sarcoma. 

The  lymphoid  cells  are  supported  in  a  delicate  reticulum  of 
a  hard  and  soft  variety.  More  or  less  fluid  may  be  present,  and 
it  may  be  gray  or  white  in  color,  with  no  distinction  between 
the  cortical  and  medullary  portions.  The  cells  are  greatly  in- 
creased in  number.  The  harder  growths  are  yellowish  white 
and  dry,  rarely  spreading  beyond  the  capsule,  and  never  under- 
going cheesy  degeneration.  Suppuration  is  rare.  The  capsule 
is  thickened  with  fibrous  bands  which  pass  through  the  mass. 
It  is  found  oftener  in  men  than  in  women,  the  ratio  being  three 
to  four.  The  lungs  of  the  cobalt  miners  of  Schneeberg  are  said 
to  be  invariably  affected  with  lymphosarcoma. 

CHONDROMA — Chondromata  usually  appear  in  cartilage 
(enchondromata),  but  may  originate  in  the  absence  of  cartilage 
(ecchondromata).  In  the  lung,  however,  its  origin  appears  to 
be  in  the  bronchia. 

Ecchondromata  are  rare,  but  enchondromata  are  not  so  rare. 
The  latter  may  be  composed  of  hyaline  cartilage,  fibrocartilage, 
or  osteoid  tissue.  They  may  be  soft,  or,  partially  or  com- 
pletely ossified.  Chondromata  are  often  the  result  of  trauma, 
and  may  be  combined  with  sarcoma.  The  case  of  primary  en- 
chondroma  reported  by  Courment  gives  such  a  history. 
(Lyon  Med.,  1895,  Ixxviii.,  pp.  259-261). 

OSTEOMA — There  are  three  varieties  of  tumors  formed  of 
osseous  tissue,  i.e..  Osteoma  durum  or  eburneum ;  Osteoma 
spongiosum;  Osteoma  medullosum.  The  first  is  formed  of 
exceedingly  hard  tissue  which  resembles  the  cement  substance 
of  the  teeth.  The  second  is  formed  of  spongy  bone-tissue,  with 
narrow  trabeculse,  and  wide  medullary  spaces.  The  third  has 
medullary  spaces  filled  with  marrow.  All  the  osteomata  agree, 
structurally,  with  normal  bone-tissue  in  the  main  points,  but 
differ  in  not  having  the  regular  architecture  of  the  bone  tra- 
beculse,  and  in  not  having  the  typical  arrangement  of  the  vascu- 
lar and  medullary  canals  and  bone-corpuscles. 


424  THE  SURGERY  OF  THE  LUNGS 

The  osseous  and  cartilaginous  tumors  are  said  to  be  more 
frequent  in  youth,  but  do  not  appear  in  young  children.  They 
are  also  more  frequent  in  men  than  in  women.  Osteomata  are 
frequently  found  in  the  lung  in  the  form  of  thin  plates.  They 
are  of  very  slow  growth.  Some  writers  think  there  is  a  heredi- 
tary disposition  to  these  growths,  especially  for  the  mutiple 
variety. 

Osteomata  in  the  lungs  are  supposed  to  be  due  to  syphilis, 
or  gout.  They  do  not  often  reveal  their  presence  during  life; 
they  are  usually  found  on  autopsy. 

The  removal  of  osteomata  is  to  be  considered  only  when  they 
become  troublesome ;  doubt  always  prevailing  as  to  their  charac- 
ter before  exposure  of  the  lung,  prior  to,  or,  after  death.  When 
surgical  intervention  is  employed,  they  should  be  removed  in 
the  same  manner  as  other  foreign  bodies,  or  benign  tumors. 

Brambella  (Gac::.  Med.  Lomb.,  Milan,  1895,  liv.,  128- 
130)  reported  a  case  of  multiple  osteoma  of  the  lung  which  was, 
perhaps,  due  to  gout  or  syphilis,  the  history  of  injury  being 
absent. 

DERMOIDS  may  be  found  in  one  or  both  lungs,  but  usually, 
in  one  only.  They  are  rare,  however,  and  are  found,  as  a  rule, 
on  autopsy.     Their  variety  is  shown  by  the  few  cases  reported. 

Goodlee  opened  a  dermoid  cyst  of  the  lung,  removed  the 
processes  and  drained  with  recovery  {Trans.  Mcd.-Chir. 
Soc,  1889).  Sormain  of  Milan  mentions  a  case  of  dermoid 
cyst  {Gazz.  d'Osp.,  Milan,  1890,  xi.,  314-332).  Ogle  also 
described  in  detail  a  dermoid  growth  in  the  lung  {Trans. 
Path.  Soc,  Lond.,  1896-97,  xlviii.,  37-39).  The  amount 
and  character  of  dermoid  tissue  in  the  lung  varies,  as  it  does 
in  other  organs  of  the  body. 

Included  in  this  group  are  the  following  four  rare  growths : 
Lymphoma,  Chondroma.  Osteoma,  and  Dermoids. 

Lymphomata  are  the  most  treacherous  of  this  class  owing  to 
their  sarcomatous  characteristics.  The  remaining  three  are 
harmless,  unless  their  growth  should  be  continuous,  when  the 


Plate  LXV. 


ipf3t_..W<.^ 


Experiment  un  Lungs,  Xo.  6,  page  488. 


LYMl'llOiMA— CHONDROMA,  OSTEOMA,  DERMOID  TUMORS     425 

danger  would  be  due  to  increased  size.  They  would  then  act 
mechanically.  But  this  is  a  rare  occurrence,  especially  in  the 
lungs. 

All  benign  neoplasms,  as  a  rule,  seem  to  be  limited  in  growth 
in  the  lungs. 

Treatment. — Lyinphomata  should  be  dealt  with  in  as  radi- 
cal a  way  as  sarcomata  and  in  the  same  manner. 

Chondrouiata,  because  of  their  position  at  or  near  the  base 
of  the  lung,  almost  preclude  the  possibility  of  attack.  Not  so, 
however,  with  the  osteomata.  These  are  usually  numerous 
small  bodies  located  here  and  there  in  the  parenchyma.  Their 
removal  offers  little  hope  of  success,  as  the  bodies  are  too  small 
to  justify  search  for  them.  If,  however,  an  osteoma  should 
be  large  enough  to  be  detected  with  the  finger,  or  otherwise,  its 
removal  should  be  accomplished. 

The  detection  of  dermoid  cysts  is  also  very  difficult.  Gen- 
erally, they  are  small,  but  when  detected  they  should  be  incised 
and  their  contents  removed  through  the  chest  wall.  Dissection 
of  the  tumor  capsule  is  not  necessary,  as  the  cavity  can  be 
treated  much  in  the  same  manner  as  in  the  removal  of  other 
growths. 

In  conclusion  it  may  be  said  that  a  benign  tumor  requires 
no  interference,  except  when  troublesome  on  account  of  size. 
A  malignant  tumor  cannot  be  entirely  removed. 


CHAPTER    XVII 
MALIGNANT   TUMORS— SARCOMA,    CARCINOMA 

There  having  been  numerous  reports  of  malignant 
growths  of  the  hmg  before  a  classification  of  malignant  tumors 
had  been  made,  it  is  necessary  to  consider  "  cancer  "  as  then 
used  to  be  a  general  term  covering  all  malignant  growths. 

Historical  (1833-1903). — Bricheteau's  work  published  in 
1833  has  some  suggestive  things  bearing  on  this  subject.  It 
reported  a  doubtful  case  of  the  lungs,  with  irreducible  omental 
hernia.  Begbie  (i860)  had  a  case  of  mediastinal  and  pulmo- 
nary cancer,  attended  by  great  local  dropsy.  Russell  (1869) 
reported  a  case  of  primary  cancer  of  the  lung,  simulating  pleu- 
ritic effusion.     Experimental  paracentesis  was  done.     Moore 

( 1890)  reported  a  new  growth  in  the  mediastinal  gland  and  left 
lung,  in  a  boy  aged  ten  years.  Schwable  ( 1891)  published  his 
hand-book  on  cancer  of  the  lung.     Spillman  and  Haushalter 

( 1891 )  published  a  paper  on  the  diagnosis  of  malignant  tumors 
in  the  lungs. 

Satterwaithe  (1891-92)  reported  rare  pulmonary  growths. 
Leprevost  ( 1892)  reported  a  case  of  cancer  of  the  left  lung  in  a 
peasant.  The  lung  weighed  eight  kilogrammes,  and  the  cancer 
finally  invaded  the  abdominal  cavity.  Powell  ( 1892)  reported 
a  case  of  malignant  disease  invading  the  right  lung,  compli- 
cated w'ith  gastric  ulcer.  Drysdale  (1892)  also  reported  a 
case  of  cancer  of  the  left  lung.  Jappa  reported  an  exactly  sim- 
ilar case.  Leech  ( 1892)  had  a  case  of  cancer  of  the  lung,  ter- 
minating in  softening  and  cavity,  and  complicated  with  paren- 

426 


MALIGNANT   TUMORS — CANCER,    SARCOMA,   CARCINOMA     427 

chymatous  nephritis.  Inurrigarre  ( 1892)  had  a  case  of  malig- 
nant tumor  complicated  with  pleuropneumonia.  Jepha  ( 1892) 
reported  a  case  of  primary  lung  cancer.  Anderson  ( 1893)  had 
a  case  of  cancer  of  the  lung  complicated  with  secondary  cancer 
of  the  liver.  Siegert  (1893)  published  a  paper  on  the  histo- 
genesis of  primary  lung  cancer. 

Passow  (1893)  published  a  treatise  on  the  differential  di- 
agnosis of  tumors  of  the  lungs,  and  Steel  (1894)  gave  a  clinical 
lecture  on  a  case.  Foa  (1894)  also  reported  a  case  of  haemo- 
thorax,  and  cancer  of  the  lung.  Betschart  (1895)  published 
his  work  on  the  diagnosis  of  malignant  lung  tumors  by  means 
of  the  sputum.  About  this  time  appeared  several  reports  on 
primary  cancer  of  the  lungs,  the  reports  of  Loomis,  and  De 
Renzi  on  primary  cancer  of  pleuritic  form,  and  Meuner's  case 
of  cancer  of  the  bronchus. 

Wolf  ( 1895)  ^^so  reported  a  case  of  primary  cancer.  Alder 
(1896)  published  a  paper  on  the  diagnosis  of  malignant 
tumors  of  the  lung.  Kazem-Beck  (1897)  added  much  to  this 
subject  by  his  report  of  two  cases  of  primary  cancer  of  the  lung, 
and  one  of  cancer  of  the  mediastinum.  Lenhartz  (1897)  had 
a  case  of  primary  lung  and  pleural  cancer.  Simmonds  ( 1898) 
produced  a  work  on  the  histology  of  primary  lung  cancer  and 
Lazarus  (1898)  also  reported  malignant  tumors  of  the  anterior 
mediastinum  and  lung. 

Kazem-Beck  (1898)  again  reported  two  cases  of  primary 
lung  cancer.  Tubenthel  (1898)  published  a  paper  on  opera- 
tions for  cancer  of  the  lung.  Guralanos  (1898)  contributed 
to  the  literature  on  this  subject,  his  study  of  the  operations  for 
pneumothorax,  and  resection  for  cancer  of  the  lung.  Yappa 
and  Pensuti  (1898)  also  had  papers  on  primary  cancer  of  the 
lung,  while  Claisse  (1899)  placed  the  profession  under  obliga- 
tions by  his  paper  on  diagnosis. 


428  THE  SURGERY  OF  THE  LUNGS 


BIBLIOGR.\PHY 

Bricheteau,  Gaz.  d.  Hop.  de  Paris,  1833,  VII,  281. 

Brixton,  Cancer  (?),  Trans.  Path,  boc,  London,  1855-56,  VII, 

7072. 
Begbie,  Arch.  Med.,  London,  1860-61,  II,  145-151. 
Russell,  Lancet,  London,  1869, 1,  814. 
Moore,  Laticel,  London,  1890,  II.,  876. 

ScHWABLE,  Med.  Wochenschr.,  Leipsic,  1891,  XVII,  1235-1238. 
Spillman  and  Haushalter,  Hebd.  de  Med.,  Paris,  1891,  2  s., 

XVIII,  575-587. 

Satterwaithe,  Post  Graduate  Journal,  New  York,  1891-92,  VII, 

125-129. 
Leprevost,  Bull,  et  Mem.  Soc.  de  Ch.,  Paris,  1892,  n.  s.,  XVIII, 

115-117. 
PowTELL,  Middlesex  Hosp.  Reports,  1892,  London,  1894,  87. 
Drysdale,  Med.  Press  and  Circ,  London,  1892,  n.  s.,  LIII,  528. 
Jappa,  Bolnitsch  Gaz.,  St.  Petersburg,  1892,  III,  153-183. 
Leech,  Chronicle,  Manchester,  1892,  XVL,  178-184. 
Lntjrrigarro,  Rev.  Soc.  Melargent,  Buenos  Aires,  1892, 1,  305-308. 
Jepha,  Berlin,  1892,  30  p. 

.Ajstderson,  Glasgow  Med.  Journal,  1893,  XXXIX,  94-96. 
SiEGERT,  Arch.  }.  Path.  Anat.,  Berlin,  1893,  CXXXIV,  287-318. 
Passow,  Berhn,  1893,  37  p. 
Steel,  Lancet,  London,  1894,  I,  388-390. 
FoA,  Gior.  d.  r.  Acad,  di  Med.  di  Torino,  1894,  XLII,  III. 
Sptllmann,  Rev.  Med.  de  I' Est,  Nancy,  1894,  XXVI,  705-711. 
Betschart,  Path.  Anat.,  Berlin,  1895,  CXLII,  86-100. 
Looms,  Med.  Rec,  New  York,  1895,  XL VIII,  167. 
De  Renzi,  Rev.  Clin,  e  Terap.,  Napoli,  1895,  XVII,  57. 
Meuner,  Arch.  Gen.  de  Med.,  Paris,  1895,  I,  343-352. 
Wolf,  Forisch.  d.  Med.,  Berlin,  1895,  XIII,  725-765. 
Abler,  New  York  Med.  Jour.,  1896,  LXVIII,  173-204. 
Kazem-Beck,  Med.  Ohozr.  Mask.,  1897,  XLVIII,  3-13. 
Lenhartz,  Munch.  Med.  Wochenschr.,  1897,  1488-1514. 


Plate  LXVI. 


Exi'ERiAii£XT  OX  LuxGS,  Xo.  /.  page  488. 


MALIGNANT   TUMORS — CANCER,    SARCOMA,    CARCINOMA     429 

SiMMONDS,  Munch.  Med.  Wochenschr.,  1898,  189. 

Lazarus,  Berl.  Klin.  Wochenschr.,  1898,  175. 

Kazem-Beck,  Centrhl.  /.  Inn.  Med.,  1898,  281-290. 

TuBENTHEL,  Deut.  Med.  Aerztl.  Ztschr.,  1898,  XXVI,  552-559. 

Guralanos,  Zeitschr.  }.  d.  Chir.,  1898,  XLIX,  497-536. 

Yappa,  Bolontsck.  Gaz.  Botkino,  St.  Petersburg,  1898,  XIX,  927- 

930- 
Pensuti,  Gaz.  d'Osp.,  Milano,  1898,  XIX,  1576. 
TucHENDLER,  Medjcyna  Warszawa,  1898,  XXVI,  715-717. 
Claisse,  Bull,  et  mem.  Soc.  Med.  d.  Hop.,  Paris,  1899,  XVI,  46-49. 
Schmidt,  M.,  Zur  casuistik  des  primaren  lungenkrebs  Inaug-Diss., 

Jena,  1900,  Feb. 
Chrisditis  a..  Contribution  a  I'etude  des  symptomes  et   du  dia- 
gnostic du  cancer  primitif  du  poumon.     Rev.  Med.-Pharm., 

Constant,  1900,  XIII,  74-78. 
Gueldre,   Du  Cancer  generalise  des  deux  poumons;  autopsie. 

Ann.  et  Bull.  Soc.  de  Med.  d'Anvers,  1900,  LXII,  83-89. 
GuTTMANN,  J.,  Consideratinni  aspura  cancerului  pulmoner.     Spi- 

talul.  Bacuresci,  1900,  XX,  226-240. 
Geisler,  T.  K.,  Lefons  cliniques  d'un  cas  de  cancer  primitif  du 

poumon.     Vratch,  St.  Petersburg,  1901,  XXII,  729-732. 
Olmer,  Tuberculose,  et  cancer  primitif  du  poumon,  Marseille  Med. 

1901,   XXXVIII,    279-284. 
Sarda  et  Oulie,  Un  cas  de  cancer  primitif  du  poumon.  Echo 

Med.,  Toulouse,  1901,  XV,  265-266. 
Shaw,  H.  B.,  Brit.  Med.  Journal,  London,  1901,  I,  1331,  1333; 

2  fig. 
RiSPAL,  Cancer  primitif  du  poumon.     Echo  Med.,  Toulouse,  1901, 

XV,  65-69. 
NicoLLE  ET  Halipre,  Canccr  secondaire  du  poumon  (presenta- 
tion de  pieces).     Normandie  Med.,  Rouen,  1902,  XVIII,  163- 

164. 

SARCOMA. — While  rare,  sarcoma  is  said  to  be  the  most 
common  of  the  malignant  growths  of  the  lung.  It  may  be  of 
primary   or    secondary    origin.     When    primary,    it    develops 


430  THE  SURGERY  OF  THE  LUNGS 

from  the  larger  bronchia,  usually  at,  or  near  their  base.  The  de- 
velopment is  rapid,  gradually  involving  the  bronchial  tract,  and, 
subsequently,  the  lung  tissue  proper.  Haemorrhage  is  rare,  and 
when  it  does  occur,  is  likely  to  be  fatal. 

Historical  (183 3- 1903). — The  year  1890  saw  the  first  pub- 
lished account  of  these  tumors.  Although  the  year  previous 
Davies  had  reported  a  case  of  lymphosarcoma  of  the  left  lung, 
yet  in  1890,  Kozlowski  and  Marini  reported  cases  in  addition 
to  that  reported  the  same  year  in  Berlin. 

Sangelli  (1888)  reported  a  case,  but  he  seems  to  have  been 
a  little  doubtful  as  to  the  diagnosis.  Jackson  (1890)  also  re- 
ported a  case  of  secondary  adenosarcoma  of  the  lung,  and 
Schech  was  another  who  appeared  in  print  on  the  same  subject. 

Vandervelde  (1892)  produced  a  paper  on  a  case  of  primi- 
tive encephaloid  sarcoma  of  the  lung.  Rolleston  (1890)  re- 
ported a  case  of  myxosarcoma  of  the  lung.  Barclay  (1892), 
Ferrand,  and  Mirinescu  (1893),  reported  cases  of  sarcoma. 
West  (1894)  had  a  case  of  primary  sarcoma  of  the  lung  in  a 
boy  aged  eleven.  Before  this  Ehrlich  had  reported  a  case  of 
primary  bronchial  and  lung  sarcoma.  Dolgopol  discusses  in  a 
very  interesting  way  the  question  of  sarcomatosis  of  the  internal 
organs,  and  also  reports  a  case  of  sarcoma  of  the  lung.  Pack- 
ard reported  a  case  and  Sangalli's  observations  on  sarcoma  of 
the  pleura  and  lungs  are  of  great  value.  Greenwood  reported  a 
case  of  pulmonary  sarcoma.  Besson  ( 1898)  wrote  a  report  of 
alveolar  sarcoma,  secondary  to  that  of  the  pleura  and  lung,  and 
Hooper,  Milan,  Habershon,  have  reports  of  cases  of  lympho- 
sarcoma. (For  an  interesting  account  of  osteosarcoma  of  the 
lung  see  Berl.  Klin.  Woch.,  1898,  p  349.) 

Pathology — Sarcomata  are  characterized  by  possessing  a 
large  number  of  cells  on  a  typical  connective  tissue.  The  cell 
structure  of  the  sarcomata  is  similar  to  that  of  the  granulation 
tissue  of  an  old  ulcer.  At  times  large  protoplasmic  masses, 
containing  many  nuclei,  may  be  found.  The  blood-vessels, 
which  ramify  through  these  tumors,  appear  to  be  nothing  but 


Plate  LXVII. 


ExpiiKiMENT  ON  LuNGS,  No.  8,  page  4S8. 


MALIGNANT   TUMORS— CANCER,    SARCOMA,    CARCINOMA     43 1 

channels,  surrounded  by  a  net-work  of  connective  tissue.  The 
small  vessels  are  in  direct  contact  with  the  tumor  cells.  They 
are  more  voluminous  than  blood-vessels  in  normal  tissues. 
Their  cell  walls  are  often  similar  to  the  tumor  cells.  The  sar- 
comata are  classified  according  to  the  shape  of  their  cells,  and 
also  according  to  the  other  kinds  of  tissue  that  may  be  found 
incorporated  in  the  tumor. 

Shaw  reports  a  case  of  stenosis  of  the  bronchus  and  vessel, 
associated  with  pneumonia,  produced  by  a  sarcoma  at  the  root 
of  the  left  lung.  There  was  great  resemblance  to  tuberculosis, 
microscopically,  but  a  more  minute  examination  revealed  the 
true  state  of  affairs. 

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DOLGOPOL,  Bolich  Gaz.  Boikina,  St.  Petersburg,  1895,  VI,  676-680. 
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432  THE  SURGERY   OF   THE   LUNGS 

Packard,  Med.  News,  New  York,  1897,  LXXI,  329-333. 
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1631. 
Hebershon,  Trans.  Path.  Soc,  London,  1897-98,  XLIX,  17-20. 
Burt,  S.S.,  Multiple  metastatic  sarcomata  of  the  lungs.     Phila. 

Med.  Journal,  1900,  VI,  545-550;  4  fig. 
Mayer  Paul,  Beitrag  zur  casuistik  der  primaren  lungensarkome. 

Inaug.  Diss.,  Munchen,  1900,  August  and  September. 
MiLiAN  ET  Maute,  Sarcome  primitif  du  poumon,  Bull,  et  Mem. 

Soc.  Anat.,  Paris,  1901,  III,  82-84. 
Ferrari,  C,  Due  casi  di  sarcoma  del  polmone  con  sintomi  di  para- 

lisi  simpatica  riflessa  per  compressione  della  parte  inferiore 

del  plesso  brachiale  in  Albertoni  (Pietro),  Ricerche  di  Bio- 

logia,  etc.,  Bologna,  1901,  363-372. 
BuiCLiu,  A.,  Supra  unui  caz  de  sarcom  pulmonar  secundar,  Spi- 

talul.  Bucuresci,  1902,  XXIII,  108-114. 

CARCINOMA — It  is  said  that  carcinoma  is  less  common  in 
the  tropics  than  in  the  colder  regions.  Billings  showed  that  it 
is  more  frequent  in  New  England,  New  York,  Ohio,  Michigan, 
and  the  south  Pacific;  that  it  is  less  frequent  in  the  Mississippi 
valley  and  southern  coast,  than  in  the  interior. 

Carcinoma  in  the  lung  is  less  frequent  than  sarcoma,  and 
slower  in  its  development;  both,  however,  develop  more  rapidly 
in  the  lung  than  in  any  other  tissue  of  the  body. 

Carcinoma  may  be  primary  or  secondary  in  the  lung.  It  is 
a  malignant  endothelial  and  epithelial  growth,  springing  from 
the  same  embryonic  tissue,  which  may  be  found  in  the  sputum. 

Historical  ( 1833- 1903). — Among  the  earliest  reports  is  that 


MALIGNANT   TUMORS — CANCER,    SARCOMA,    CARCINOMA     433 

of  the  surgeon  general  of  the  Marine  Hospital  ( 1889).  Wie- 
ber  (1889)  also  reported  a  case  of  primary  carcinoma  of  the 
lung  with  metastasis.  Fuchs  (1890)  published  an  article  on 
the  treatment  of  carcinoma.  In  Berlin  observations  were  made 
on  a  horse.  Hardford  ( 1889-90)  reported  a  case  of  carcinoma 
of  the  root  of  the  lung,  with  comparative  absence  of  symptoms  ; 
it  was  complicated  with  simple  gastric  ulcer,  and  death  resulted 
from  enteritis. 

Rickards  (1891)  had  a  case  of  carcinoma,  at  the  root  of 
the  left  lung,  with  extension  through  the  outer  vertebral  fora- 
men, and  compression  and  softening  of  the  spinal  cord.  Sat- 
terwaithe,  Belcher,  and  Kidd  (1891)  reported  cases.  Kidd's 
case  was  very  interesting,  one  of  mediastinal  and  pulmonary 
carcinoma,  associated  with  retraction  of  the  chest  wall.  Simon 
( 1893)  published  a  case  of  primary  carcinoma  of  the  lung  with 
secondary  deposits  in  the  liver,  brain,  and  scapula.  Perinato 
also  reports  a  case. 

Wolfe  reported  thirty-one  cases  of  primary  carcinoma  of 
the  lung  in  seven  thousand  necropsies ;  there  were  twenty-seven 
men  and  four  women,  of  whom  the  youngest  was  thirty-six  and 
the  oldest  seventy.  In  jfive  cases,  the  right  lung  was  affected, 
in  three  cases,  the  left.  The  right  bronchus  was  the  seat  of 
disease  in  thirteen  cases,  and  the  left  bronchus  in  eight  cases. 
In  two  cases,  both  bronchi  were  affected.  In  thirteen  cases, 
there  were  tuberculous  complications,  and,  more  likely,  metas- 
tasis in  cases  of  bronchial  origin. 

Hampeln  (1897)  gave  an  extended  account  of  carcinoma, 
and  Pfarmenstill  (1897)  published  his  observations  on  primary 
carcinoma.  Scotti  (1898)  reported  on  diffuse  pulmonary  car- 
cinoma. Le  Count  reported  a  case  of  diffuse  secondary  carci- 
noma, confined  to  the  lymph  channels  of  both  lungs.  The  ne- 
cropsy discovered  many  metastatic  tumor  nodules  in  various 
organs.     The  primary  tumor  was  located  near  the  pylorus. 

As  the  edge  of  the  right  pleura  lies  between  the  oesophagus 
and  aorta,  it  is  very  probable  that  a  carcinoma  of  the  oesophagus 


434  THE   SURGERY   OF   THE    LUNGS 

may  extend  to  the  right  pleura,  and  thence  to  the  right  lung, 
and  vice  versa. 

Pathology — Carcinomata  are  formed  of  true  epithelial  cells ; 
but  they  grow  in  an  irregular,  atypical  manner.  This  is  due, 
some  claim,  to  the  difference  in  pressure  exerted  by  the  various 
kinds  of  tissue  in  which  they  grow.  They  are  arranged  in 
alveoli,  the  latter  round,  elongated,  club-shaped,  etc.,  and  are 
formed  of  single  cells  in  close  contact,  with  no  connective  tissue 
between  the  alveoli. 

There  is  no  essential  difference  in  structure  of  the  various 
kinds  of  carcinomata  which  originate  in  the  surface  epithelium ; 
the  same  may  be  said  of  those  which  have  a  glandular  origin ; 
but  between  those  of  glandular  origin  and  those  formed  in  the 
surface  epithelium  there  is  sufficient  difference  to  enable  them 
to  be  classified.  Still  the  difference  is  only  in  their  microscop- 
ical appearance. 

Weinburger  reported  two  cases  of  primary  bronchial  carci- 
noma. One  resembled  tuberculosis.  A  third  case,  in  a  young 
woman,  was  a  lymphosarcoma  of  the  mediastinum,  which  in- 
vaded the  lung.  (ZeitscJu'ift  fi'ir  Hcilkiinde,  volume  xxii, 
part  2,  February,  1901.)  Heidenhain  of  Worms  (Ninth  Ger- 
man Congress,  April,  1901)  reported  a  resection  of  a  lung  for 
the  removal  of  a  carcinoma ;  later,  because  of  bronchiectasis,  he 
had  to  make  longitudinal  incisions  in  the  bronchial  tubes,  to 
evacuate  pus. 

The  most  usual  intrathoracic  cancer  is  the  medullary  or  en- 
cephaloid.  Infrequently,  a  scirrhous  cancer  may  be  thus  situ- 
ated, and  there  are  a  few  reports  of  colloid. 

Many  malignant  growths  are  metastatic  in  origin,  especially 
those  found  in  the  lungs.  Walshe  claims  that  cancerous  dis- 
eases of  the  testicle  may  be  followed  by  pulmonary  cancer.  Le- 
bert  says  that  duration  of  life  is  from  one  to  two  years,  and  in 
some  cases  several  years. 

Symptoms. — Pain,  cough,  and  expectoration,  the  latter  be- 
coming mucopurulent,  and  sometimes  presenting  the  appear- 


Plate  LXVIII. 


ExpERiMEXT  ON  LuNGS,  No.  lo,  page  489. 


MALIGNANT   TUMORS — CANCER,    SARCOMA,    CARCINOMA     435 

ance  of  currant  jelly.  This  peculiar  appearance  of  the  sputum 
is  somewhat  diagnostic.  There  is  dulness  on  percussion  and 
the  respiratory  murmur  is  either  suppressed  or  modified. 

Treatment. — Unfortunately  the  removal  of  such  growths 
offers  but  little  encouragement.  Prognosis  would,  however, 
become  more  favorable  if  the  neoplasms  could  be  removed  ear- 
lier in  their  development.  This  is  hardly  possible,  owing  to  the 
lung  being  inaccessible  without  opening  the  chest  wall,  which 
is  not  justifiable  until  the  destruction  of  the  lung  has  become 
too  far  advanced  for  safety. 

Operative  measures  are  especially  undesirable  if  the  origin 
of  the  growth  is  in  a  bronchial  gland  or  the  base  of  the  lung. 
However,  if  the  growth  involves  the  apex  of  the  lung,  and  its 
removal  be  made  early,  much  encouragement  may  ensue. 

As  in  all  other  operations  upon  the  lung,  resection  of  one  or 
more  ribs  is  necessary  at  a  point  most  convenient  for  attack.  It 
is  also  desirable  in  this,  as  in  the  majority  of  lung  operations, 
to  have  adhesions  of  the  visceral  to  the  parietal  pleura.  The 
removal  of  the  diseased  tissue  with  the  knife,  ligature,  cautery, 
or  otherwise  should  be  followed  by  securing  the  bleeding  vessels 
and  smaller  bronchia  with  ligature,  or  clamp,  or  both,  with  suf- 
ficient pressure  with  gauze  packing  to  prevent  bleeding  and  the 
escape  of  air.  Drainage  is  more  easily  and  perfectly  accom- 
plished in  all  pathologic  conditions  involving  the  lower  portion 
of  the  lung.  If  only  one  lobe  be  involved,  complete  removal  of 
that  lobe  should  be  practised  with  thorough  drainage  by  gauze. 

BIBLIOGRAPHY 

Report  Sup.  Surg.  Gen.,  Marine  Hosp.,  Washington,  1889;  314. 

WiEBER,  Berlin,  1889,  32  p. 

FucHS,  Leipzig,  1890,  24  p. 

Grammlkh,  Ztschr.  f.  Vetermark,  Berlin,  1890-91,  II,  445-448. 

Rep.  Sup.  Surg.  Gen.  U.  S.  Marine  Hosp.,  Washington,  1889- 

90;  XVIII,  202. 


436  THE  SURGERY  OF  THE  LUNGS 

Hardford,  Trans.  Path.  Soc,  London,  1889-90,  XLI,  37-40. 

Peabody,  Med.  Rec,  New  York,  1891,  XXXIX,  438. 

RiCKARDS,  Brit.  Med.  Jour..,  London,  1891,  II,  13. 

Satterwaithe,  Med.  Rec,  New  York,  1891,  XL,  257-264. 

Belcher,  Brooklyn  Med.  Jour.,  1891,  V,  703-707.  Rep.  Sup. 
Surg.  Gen.,  Marine  Hosp.,  Washington,  XIX,  1890-91;  153. 

KiDD,  Trans.  Clin.  Soc,  London,  1891-92,  XXV,  178-180. 

Simon,  Birmingham  Med.  Rev.,  1893;  XXXIV,  81-85. 

Perinato,  Rev.  Veneta  di  Sc.  Med.,  Venezia,  1893;  XIX,  393-399- 

Wolfe,  Deutsch.  Med.  Wochenschr.,  1896,  No.  11,  p.  365. 

Hampeln,  Ztschr.  Klin.  Med.,  1897,  XXXI,  247-259. 

Pfarmenstill,  C.  C.  R.,  No.  38-15-17.  Nord.  Med.  Ark.,  Stock- 
holm, 1897. 

ScoTTi,  N.  Riv.  Clin.  Therap.,  Napoli,  1898,  I,  57-59. 

Sailer,  Contrib.  f.  Wm.  Pepper  Lab.  of  Clin.  Med.,  Philadelphia, 
1900,  416-446;  2  p. 

Parascandolo,  Arte  Med.,  Napoli,  1900,  II,  441-444,  461-466. 

Hay,  Liverpool  M.-Chir.  Jour.,  1901,  XXI,  155-156. 

Lammerhirt,  Inaug.-diss.  Griefswald,  1901,  Mai. 

Cloin,  Prag.  Med.  Woch.,  1901,  XXVI,  275-276. 

DiNKLER,  Verhandl.  d.  Deutsch  Pati.  Gesellsch.,  Berlin,  1901,  III, 
59-61. 

Le  Count,  Jour.  Am.  Med.  Assn.,  Vol.  XXXVI,  p.  589,  1901. 

Delorme,  Inaug.-diss.,  Jena,  1902,  Januar. 

BoTTGER,  Munchen  Med.  Wochenschr,  1902.     XLIX,  272-273. 


CHAPTER  XVIII 

BACILLI— BACILLUS  ANTHRACIS,   BACILLUS   (EDEMATIS 
MALIGNI,    BACILLUS    AEROGENES     CAPSULATUS, 
BACILLUS  PNEUMONIA,  BACILLUS  TUBER- 
CULOSIS,   BACILLUS    TYPHOIDES 

ANTHRAX. — This  disease  is  very  frequent  in  Russia,  Hun- 
gary, France,  and  Saxony,  and  it  occurs  as  an  epidemic  in  Si- 
beria, and  India.  It  is  only  occasionally  found  in  man  or  beast, 
in  the  United  States. 

Historical  ( 1850-1903). — Bacillus  anthracis  was  discovered 
by  Davaine  and  Rayer,  who  reported  to  the  Academic  des  Sci- 
ences (1850)  the  finding  of  small  filiform  bodies  in  blood  in 
length  about  twice  the  diameter  of  a  red  blood  corpuscle. 
Grouin  states  that  fifty-six  thousand  cattle  died  of  this  disease 
in  Novgorod,  Russia,  between  the  years  1867  and  1870. 

Among  the  domesticated  animals,  cows,  sheep,  and  horses 
are  more  susceptible  than  asses,  goats,  and  hogs.  Mice,  rab- 
bits, and  guinea-pigs  are  especially  susceptible  to  infection.  It 
is  difficult  to  infect  dogs  and  poultry. 

Bacillus  anthracis  was  the  first  to  be  discovered  and  is, 
therefore,  of  great  interest,  because  it  was  the  foundation  upon 
which  the  science  of  bacteriology  has  been  built.  Pasteur  suc- 
ceeded Davaine  in  the  study  of  this  bacillus,  but  the  discovery  of 
spores  was  not  made  until  Koch  reproduced  the  disease  by 
inoculating  animals.  It  was  he  who  maintained  that  an  infec- 
tion could  take  place  through  the  organs  of  respiration  ;  he  had 
placed  a  mouse  under  a  bell-jar  containing  the  bacilli,  with  fatal 
results. 

437 


438  THE  SURGERY  OF  THE  LUNGS 

The  period  of  incubation  is  from  a  few  hours  to  three  or 
four  days. 

Schottmuller  (1898)  reported  two  cases  of  anthrax  in  the 
lung.  One  of  the  patients  was  a  maker  of  baskets  from  strips 
of  hide ;  in  the  other  case  the  cause  could  not  be  ascertained. 

All  those  who  work  among  cattle,  sheep,  wool,  hides,  etc., 
are  exposed  to  infection.  The  domesticated  animals,  indige- 
nous to  Algeria,  seem  to  possess  immunity  from  this  dreaded 
disease.  Salines  in  the  soil,  combined  with  warmth  and  mois- 
ture, are  supposed  to  favor  the  development  of  the  bacillus, 
hence  the  disease  is  prevalent  along  rivers  and  low  lands. 

Symptoms. — Onset  sudden ;  dyspnoea ;  headache ;  chill ;  fever ; 
nausea ;  gastralgia ;  coryza ;  lacrymation ;  exhaustion ;  consoli- 
dation of  lung;  temperature,  later  on,  sub-normal;  sputum,  al- 
though often  like  prune  juice,  is  not  characteristic.  The  out- 
come of  the  disease  is  very  uncertain. 

BACILLUS   (EDEMATIS   MALIGNI Previous   to   Lister's 

great  discovery,  this  organism  caused  many  deaths  from  pro- 
gressive gangrenous  oedema  and  emphysema. 

Its  habitat  is  decaying  matter,  dust  of  dwellings,  old  rags, 
hay,  etc.  It  is  often  associated  with  the  bacillus  tetanus  in 
earth  which  has  been  fertilized  with  foul  faecal  matter.  Rich 
garden  earth  has  been  used  to  inoculate  animals  by  being  in- 
jected, subcutaneously. 

The  internal  organs  are  only  slightly  affected  by  this  ba- 
cillus. But  the  bacilli  are  found  on  all  serous  surfaces.  It 
makes  its  appearance  in  the  blood  only  after  death. 

This  bacillus  resembles  the  bacillus  anthracis.  The  colonies 
have  a  granular  appearance.  They  form  long  chains  which  are 
often  twisted.  They  have  no  independent  motion.  Spores  are 
found  in  individual  bacilli,  but  not  in  threads.     It  is  anaerobic. 

(See  chapter  on  CEdema,  for  a  fuller  description  of  this 
disease,  etc.) 

BACILLUS  AEROGENES  CAPSULATUS  (Gas  Bacillus) The 

bacillus  aerogenes  capsulatus,  described  by  several  investigators 


Plate  LXIX. 


Experiment  on  Lungs,  No.  ii,  page  489. 


BACILLI  439 

(see  bibliography),  is  probably  the  cause  of  emphysematous 
gangrene  in  the  lung  as  elsewhere.  Although  found  most  fre- 
quently in  cases  of  trauma,  it  also  has  been  observed  in  non- 
traumatic cases. 

Ohlmacher  says  that  this  bacillus  "  was  not  found  in  smears 
or  cultures  of  the  heart's  blood,  but  it  was  found  after  inocula- 
tion of  heart's  blood  into  rabbits,  which  were  killed  and  in 
twenty-four  hours  presented  the  characteristic  lesions.  An 
organism  corresponding  morphologically  and  tinctorially  with 
the  gas  bacillus  was  found  in  the  heart  muscle,  lung,  kidney, 
and  liver.  In  all  of  these,  gas  bubbles  were  also  found  on 
microscopic  examination.  Cultures  from  the  heart's  blood 
showed  Staphylococcus  aureus.  Streptococcus  pyogenes  and  the 
colon  bacillus."     {Amer.  Medicine,  July  27th,  1901,  vol.  ii,  p. 

137- ) 

Loeb,  in  the  same  article,  states  that  "  the  bacillus  of  malig- 
nant cedema  rarely,  if  ever,  produces  those  lesions  which  were 
always  attributed  to  it."  "  The  bacillus  aerogenes  capsulatus, 
or  Bacillus  Welchii,  practically  dominates  the  whole  field  of 
pneumatopathology. " 

This  organism  is  extremely  virulent,  but  there  is  great 
variation  in  its  action.  One-half  of  the  sixty  reported  cases  of 
emphysematous  gangrene,  caused  by  the  gas  bacillus,  have  been 
fatal.  The  majority  of  the  other  half  have  either  been  mild, 
or  recovery  quickly  ensued  upon  an  operation.  Even  in  severe 
cases,  if  the  patient  lives,  the  bacillus  will  die  in  ten  days  or 
two  weeks.  Mild  cases  have  been  known  to  recover  sponta- 
neously. This  bacillus  gains  a  foothold  in  healthy  tissue  only 
with  the  greatest  difficulty. 

The  intestine  is  also  one  of  the  habitats  of  the  gas  bacillus, 
but  thus  it  usually  does  little  harm  except  in  case  of  typhoid 
perforation,  appendicitis,  or  strangulation.  In  some  cases  gas 
is  not  found  in  the  tissues  until  after  death ;  again,  there  are 
cases  in  which  the  tissues  do  not  produce  gas. 

The  bacillus  aerogenes  capsulatus  is  large  and  thick,  and  is 


440  THE  SURGERY  OF  THE  LUNGS 

one  of  the  encapsulated  bacilli.  It  is  not  very  active,  but  it  has 
not  been  decided  whether  it  is  motile  or  not.  It  is  supposed  to 
be  anaerobic. 

BIBLIOGRAPHY 

(Bacillus  aerogenes  capsulatus.) 

Bulletin  oj  Johns  Hopkins  Hosp.,  1892,  Vol.  Ill,  pp.  81-91. 
Annals  0}  Surgery,  1894,  Vol.  XIX;  pp.  187-196. 
Centralhlatt  }ur  Bakteriologie,  1893,  ^^^-  XIII,  pp.  13-16. 
Bulletin  oj  Johns  Hopkins  Hosp.,  1897,  Vol.  VIII,  pp.  24-28. 
Progressive  Medicine,   December,   1899. 
Boston  Med.  and  Surg.  Jour.,  1900,  Vol.  CXLIII,  pp.  73-87. 

BACILLUS  PNEUMONIA — Pneumonococcus  (Friedlaen- 
der)  is  found  in  the  alveolar  exudate,  and  in  the  exudates  from 
the  pleura,  and  pericardium,  in  cases  of  croupous  pneumonia. 
It  has  been  found  in  the  rusty  sputum  and  blood.  It  is  not  a 
reliable  diagnostic  test,  as  there  are  other  bacilli  which  resemble 
it,  and  because  other  varieties  of  bacilli  also  cause  pneumonia. 

This  bacillus  is  short  and  thick,  somewhat  resembling  cocci. 
It  is  enveloped  in  a  gelatinous  capsule,  sometimes  a  single  cap- 
sule containing  two  or  more  bacilli.  It  has  no  independent  mo- 
tion. The  colonies  are  white,  with  knob-like  projections  above 
the  surface. 

BACILLUS  TUBERCULOSIS  is  the  active  cause  of  tuber- 
culosis, lupus,  and  scrofula.  No  animal  seems  to  have 
absolute  immunity  from  the  ravages  caused  by  this  organism. 
All  the  diseases  attributable  to  this  bacillus  can  only  be  caused 
by  infection  with  the  bacilli,  or  their  spores.  Infection  is  by 
inhalation,  by  swallowing  the  virus,  and  by  inoculation. 

The  bacilli  are  found  where  the  disease  is  just  beginning  to 
attack  a  new  place.  In  the  early  stages  of  the  disease,  the  ba- 
cilli are  isolated,  and  will  be  found  in  the  cells  close  to  the 
nuclei ;  where  the  disease  has  existed  longer,  the  bacilli  will  be 


Plate   LXX. 


Experiment  on  Lungs,  No.  13,  page  489. 


BACILLI  441 

found  in  clumps.  They  are  not  readily  found  in  old  cheesy 
masses,  unless  the  latter  have  been  exposed  to  the  air.  They 
may  always  be  found  in  the  giant  cells. 

The  bacilli  are  often  curved,  or  bent  at  an  angle.  The 
spores  are  larger  in  diameter  than  the  individual  bacilli.  When 
found,  from  two  to  six  will  be  seen  together, 

BACILLUS  TYPHOIDES  (Eberth)  was  found  in  an  abscess 
of  the  lung  by  Ramsey  (1890,  Annals  of  Surgery,  January, 
p.  39).  He  also  found  it  in  a  case  of  gangrene  of  the  lung 
and  spleen. 

It  is  probably  of  secondary  and  not  primary  origin,  and 
when  found,  is  associated  with  tissue  necrosis,  arising  after  the 
third  week  from  the  onset  of  the  fever. 


CHAPTER    XIX 

PARASITIC    FUNGI— ACTINOMYCES,  ASPERGILLUS, 
PNEUMONOMYCES,    OIDIUM 

ACTINOMYCOSIS. — Actinomyces  is  a  vegetable  parasite 
found  in  animal  and  human  life,  and  is  supposed  to  be  inhaled 
after  having  colonized  in  the  mouth,  probably  in  decayed  teeth. 
Direct  infection  of  the  lung  is  very  much  questioned.  The  left 
lung  is  more  often  afifected  than  the  right,  and  resembles  a  lung 
with  fibroid  phthisis,  though  the  pearly  gray  or  yellow  nodules 
or  granules  (threadlike  in  appearance)  are  diagnostic,  as  is  the 
contracted  thorax,  later  on. 

The  granule  is  a  star-shaped  body,  composed  of  numerous 
threads  with  club-shaped  ends  which,  together  with  the  branch- 
ing segmented  mycelium,  is  characteristic.  The  pus  with 
which  it  is  associated  is  epiphenomenal,  and  the  disease  may  be 
confounded  with  abscess  or  phlegmon. 

Eighty-five  to  ninety  per  cent,  of  cases  of  involvement  of  the 
lung  terminate  fatally.  However,  the  mortality  is  very  much 
reduced  if  the  superficial  portion  of  the  lung  be  involved,  or  if 
surgical  principles  are  employed. 

The  fungus  of  actinomyces  is  from  one-half  to  two  milli- 
meters in  diameter,  and  the  nodules  which  it  forms  soon  begin 
to  decay,  but  the  process  of  growth  keeps  pace  with  that  of 
decay.  The  disease  spreads  by  the  adjoining  parts  becoming 
infected,  and  sometimes  metastasis  occurs.  It  has  been  found 
in  the  crypts  of  the  tonsils,  lacrymal  duct,  and  in  carious  teeth, 
from  which  places  it  is  easy  for  the  fungus  to  be  aspirated  into 
the  lungs. 

When  the  lung  is  involved  there  is  first  pain,  followed  by 

442 


PARASITIC   FUNGI  443 

pleurisy  and  expectoration,  pneumonia  or  bronchitis,  or  both. 
There  is  at  this  time  great  proHferation  of  round  cells,  which 
soon  undergo  fatty  degeneration,  and  an  abscess  is  formed 
which  ruptures  into  the  bronchia.  The  expectoration  is  of 
some  aid  in  making  a  diagnosis,  but  although  peculiar,  it  is 
not  definite. 

Clinically,  this  disease  can  be  diagnosticated  by  the  presence 
of  the  yellow,  seed-like  bodies  in  the  pus,  which  are  visible  to 
the  naked  eye,  and,  when  rubbed  between  the  fingers,  have  a 
greasy  feel. 

The  carnivorous  animals  appear  to  enjoy  immunity  from 
this  disease.  This,  apparently  bears  out  the  theory  that  the  dis- 
ease is  due  to  a  fungus  or  parasite  growing  on  plants,  which 
cattle  may  eat,  thus  becoming  infected  themselves,  and  in  turn 
infecting  those  who  may  eat  their  flesh. 

Historical  ( 1877-1903). — Ponfick  was  the  first  to  recognize 
this  disease  in  man.  He  had  a  case  in  which  there  was  a  meta- 
static growth  in  the  right  auricle,  and  numerous  metastases  in 
the  lungs.  (Die  Actinomykose  des  Menchen,  eine  neue  Infec- 
tionkrankeite  auf  bergleichend-pathologicher  und  experiment- 
eller  Grundlage  geschildert,  Berlin,  1882.) 

The  name  of  the  parasite  is  Actinomyces  bovis  when  found 
in  cattle,  but  some  writers  term  it  actinomyces  hominis  when 
found  in  man.  But  whether  found  in  man  or  in  animals,  it  is 
evidently  the  same  thing.  The  disease  caused  by  this  fungus 
is  termed  actinomycosis.  Some  writers  do  not  seem  to  make  a 
careful  distinction  between  the  name  of  the  plant  and  the  name 
of  the  disease;  they  use  the  terms  as  if  they  were  synonymous. 

Belfield  (1879)  '^vas  the  first  to  discover  this  disease  in 
America.  Sebert,  however  (1848),  was  the  first  to  publish 
anything  on  this  subject,  and,  like  others,  did  not  know  just 
what  he  had  found.  Bollinger  (1877)  found  it  in  animals 
and  was  the  first  fully  to  describe  the  disease ;  Dr.  J.  B.  Mur- 
phy (1884)  has  the  credit  of  being  the  first  in  the  United 
States  to  discover  it  in  man. 


444  THE    SURGERY   OF  THE   LUNGS 

Israel  published  the  results  in  thirty-eight  cases.  In  seven- 
teen cases,  the  patient  was  infected  in  the  mouth,  or  pharynx. 
In  nine  patients,  the  infection  was  in  the  air  passages  of  the 
lungs.  In  seven,  the  infection  was  at  some  point  of  the  ali- 
mentary canal,  and  in  five,  the  point  of  infection  was  uncertain. 
Israel  demonstrated  that  pure  cultures  could  be  made  and  that 
animals  could  be  inoculated  from  them.  He  also  proved  that 
rabbits  could  be  inoculated  from  man.  (Klin.  Beitrage  zur 
kenntniss  der  Aktinomykose  des  Menschen,  Berlin,  1885.) 

It  is  stated  that  the  first  case  diagnosticated  in  man  during 
life,  was  reported  February  12th,  1889,  by  Powell  and  Goodlee 
to  the  Medico-Chirurgical  Society.  Richeralle  (1892)  re- 
ported five  cases  of  simulating  tuberculosis.  {Miinch.  Med. 
Woch.,  1895,  p.  49.)  Partsch  (1892)  mentions  a  case  of  in- 
fection at  the  root  of  a  bicuspid  tooth.  (Die  eingang  des  Ak- 
tinomyces.  Wien.  Woch.,  1897,  p.  97.)  Heuser  (1895)  re- 
ported a  case  of  primary  actinomycosis  of  the  lung.  Aschofif 
and  Butler  each  reported  a  case  which  recovered.  Karewski, 
Caglieri,  Babrazes,  and  Visconti  have  also  contributed  to  this 
subject. 

Treatment — Ruhraeh  of  Baltimore  {Annals  of  Surg.,  vol. 
xxx)  gave  an  analysis  of  sixty-five  cases  that  had  been  re- 
ported as  occurring  in  America.  He  says  :  "  The  thoracic  cases 
do  badly  as  a  rule,  no  matter  what  treatment  is  followed."  J. 
L.  Sawyer  {Jour.  Am.  Med.  Assn.,  p.  13 14,  vol.  xxxvi,  1901) 
is  one  of  the  latest  writers  on  this  disease.  He  reports  several 
cases,  but  only  one  case  was  of  the  lung.  He  recommends  the 
administration  of  iodide  of  potassium,  combined  with  hypoder- 
mic injections  of  a  one  per  cent,  solution  of  the  same.  The  in- 
jections are  to  be  given  in  one-half  drachm  doses,  every  third 
day.  There  will  be  a  temporary  increase  in  the  symptoms,  and 
swelling  for  about  six  hours  after  an  injection.  Dr.  Sawyer 
found  threadlike  mycelia  with  clubbed  ends  in  the  urine,  and 
also  found  traces  of  indican  in  nearly  all  cases. 

Five  per  cent,  solutions  of  potassium  permanganate,  one  per 


Plate  LXXI 


Experiment  on  Lungs,,  No.  14.  page  489. 


PARASITIC   FUNGI  445 

cent,  solutions  of  methyl  violet,  and  five  per  cent,  solutions  of 
carbolic  acid  in  doses  of  fifteen  to  forty-five  minims,  have  all 
been  used  for  parenchymatous  injections. 

The  head  and  neck  are  most  frequently  the  seat  of  the  dis- 
ease. Fifty-five  per  cent,  of  all  cases  have  been  found  in  these 
parts  of  the  body,  while  twenty  per  cent,  were  in  the  thorax  or 
lungs,  twenty  per  cent,  in  the  abdominal  organs,  and  five  per 
cent,   in  all  other  parts  of  the  body. 

Garre  reports  ninety-six  cases  of  the  lung  operated  upon, 
with  eighty-seven  cases  cured. 

BIBLIOGRAPHY 

Heuser,  Berlin.  Klin.  Wochenschr.,  1895,  1029-1031. 
AscHOFF,  Berlin.  Klin.  Wochenschr.,  1895,  738-765-786. 
Butler,  Med.  News,  New  York,  1898,  LXXII,  513-515. 
Karewski,  Berl.  Klin.  Wochenschr.,  1898,  328-350-373. 
Caglieri,  Am.  Med.  Assn.  Jour.,  1898,  XXXI,  1173. 
Babrazes,  Rev.  de  Med.,  Paris,  1899,  XIX,  68-77. 
ViscoNTi,  Primary  actinomycosis  puhnonare. 
Martin,  Ztschr.  f.  Fleisch  u.  Milchhyg.     Berlin,  1900,  X,  152-153. 
Parascandolo,  C.,  Clinical  Med.,  Pisa,  1900,  VI,  353-359- 
NossoLL,  Centralhlatt  fur  die  Gienzgebirte  des  Medizin  und  Chi- 

rurgie,  June  25,  1902;  p.  466. 
Garre,  Journal  American  Medical  Ass^n.,  1902;  XXXVIII,  No. 

12,  March  22,  pp.  798-9. 

ASPERGILLUS.— Virchow  first  mentioned  it  in  1856.  It  is 
a  vegetable  parasite,  and  has  been  described  by  Freyhau  (IVieu. 
Med.  Prcsse,  1882,  p.  185).  With  the  aspergilli,  as  with  all 
other  of  the  mould  fungi  which  attack  the  human  body,  there 
is  a  tendency  to  lodge  in  some  one  of  the  internal  organs.  After 
lodgement,  the  mycelia  grow  out  and  form  distinct  foci. 

Three  species  of  aspergilli  are  known  to  be  pathogenic,  i.  e., 
Aspergillus  fumigatus,  Aspergillus  niger,  Aspergillus  flavus  or 


446  THE   SURGERY   OF   THE   LUNGS 

flavescens.  These  species  of  fungi  are  widely  distributed ;  they 
are  found  at  times  on  mouldy  bread,  etc.  Persons  should  be 
very  cautious  of  all  mouldy  foods.  Some  of  the  moulds  are 
harmless,  but  all  should  be  handled  carefully.  Birds  are  often 
observed  with  mycosis  of  the  lungs  caused  by  inhalation  of  the 
spores  of  the  aspergilli.  Other  animals  have  also  been  found 
suffering  from  accidental  infection. 

The  most  dangerous  species  is  Aspergillus  fumigatus.  This 
mould  is  greenish  in  color.  The  conidia-bearers  are  short  and 
hemispherical,  very  thickly  set  with  sterigmata.  The  latter  are, 
in  shape,  awl-like.  The  conidia  are  generally  colorless,  round 
and  smooth,  and  show  no  membrane.  This  species  is  not  known 
to  have  sclerotia.  A  temperature  of  thirty-seven  to  forty  de- 
grees Centigrade  is  best  for  its  growth. 

Aspergillus  fiavus  or  flavescens  ranks  next  to  Aspergillus 
fumigatus  in  pathogenic  power.  This  species  is  greenish- 
brown  in  color,  with  yellow  or  brown  conidia,  having  a  finely 
nodular  surface.  The  sclerotia  are  very  small  and  black.  It 
grows  best  at  about  twenty-eight  degrees  Centigrade. 

Aspergillus  niger  is  said  not  to  be  very  malignant.  It  is 
brownish-black  in  color.  The  fruit-bearers  are  globular,  and 
the  sterigmata  long  and  branching;  the  conidia,  round  and 
black,  or  nearly  so,  and  the  sclerotia,  brownish-red  and  about 
the  size  of  a  rape-seed.  The  best  temperature  for  its  growth 
is  about  thirty-five  degrees  Centigrade. 

Among  reports  of  pulmonary  trouble,  caused  by  these 
moulds,  is  that  of  Wheaton,  who  mentions  a  case  in  a  child 
two  and  one-half  years  old.  Bland  Sutton  (Trans.  Path.  Soc, 
1885)  gave  a  full  account  of  these  moulds  in  the  air-passages 
of  birds.  Kidd  (1886)  showed  by  experiment  that  the  injec- 
tion of  the  spores  of  aspergilli  into  the  auricular  veins  of  rab- 
bits produced  them  in  abundance  in  various  organs,  especially 
in  the  kidneys.  (Path.  Soc.  Trans.)  Boyce  (1892)  remarks 
upon  a  case  of  aspergillus  pneumonocoses  (Jour.  Bacter.,  Oct. 
1892).     He   found   them   in   small   irregular  cavities   in   the 


PARASITIC    FUNGI  447 

apex  of  the  lung,  forming  white  Ijodies  aljout  the  size  of  a  pin 
head,  and  resembhng  calcified  bodies.  Furbruiger  ( 1876)  col- 
lected eleven  cases  (Beobach.  iiber  Lungenmycose  beim  Men- 
schen.  Virchow's  Arch.,  1876,  p.  330).  There  is  no  general 
infection ;  and  examination  of  the  sputum  reveals  nothing.  It 
is  said  to  be  always  secondary. 

PNETTMONOMYCES.— For  over  half  a  century  this  fungus 
has  been  known  as  a  causative  factor  in  lung  disease.  The  le- 
sions are  similar  to  those  produced  by  the  other  fungi.  The 
symptoms  and  diagnosis  are  similar  to  those  of  aspergillus.  It 
is  this  reason,  perhaps,  that  has  caused  pneumonomyces  to  be 
mistaken  for  aspergillus.  It  is  only  by  a  microscopical  exami- 
nation of  the  plant  that  positive  knowledge  of  its  identity  can 
be  obtained. 

Some  writers  consider  pneumonomycosis  to  be  caused  by 
aspergilli,  or  have  confounded  the  two.  Von  Dusch  and  Pag- 
enstecher  call  it  Aspergillus  Pulmonum  Hominis.  Stieda, 
Weichselbaum,  and  Rother  also  consider  it  to  be  an  aspergillus, 
or  care  has  not  been  taken  to  differentiate  the  two. 

Historical  (1853-1903). — Bristowe  (1853-1854)  reported 
a  vegetable  fungus  growing  in  the  cavity  of  the  lung.  Cohn- 
heim  (1865)  reported  two  cases  of  fungoid  growths  in  the 
lungs.  Von  Buhl  (1878)  reported  on  pneumonomycosis  sar- 
cinica  as  a  causative  factor  in  diseases  of  the  lung.  Fuer- 
bringer  (1876)  reported  cases  of  pulmonary  disease  in  man 
caused  by  a  fungus.  Von  Ziemssen  (1876)  published  an  arti- 
cle on  pneumonomycosis.  Manwerk  (1881)  reported  cases  of 
pneumonomycosis  in  the  lung,  and  Roeckl  (1884)  also  re- 
ported cases, 

(For  symptoms,  diagnosis,  and  treatment,  see  under  these 
headings  in  the  last  chapter.) 


448  THE  SURGERY  OF  THE  LUNGS 

BIBLIOGRAPHY 

1.  Bristowe,  Trans.  Path.  Soc,  London,  1853-54,  V,  38-41. 

2.  CoHNHEiM,  Arch.  /.  path.  AnaL,  etc.,  Berlin.,  XXXIII,  157-159. 
2a.  Stieda,  Arch.  f.  path.  Anat.,  Berlin.,  1866,  XXXVI,  279. 

3.  Von  Buhl,  Aerztl.  Int.-Bl.,  Muenchen,  1876,  XXIII,  324. 

4.  FuERBRiNGER,  Arch.  j.  path.  Anat.,  Berlin.,  1876,  LXVI,  330-65. 

5.  Von  Ziemssen,  Deutsches  Arch.  j.  Klin.  Med.,  Leipzig,  1876-77. 

XIX,  344-356- 

5a.  RoTHER,  Char.-Ann.,  1877,  Berlin.,  1879,  IV,  272-77. 
5b.  Weichselbaum,    Wien.   Med.   Wohnschr.,    1878,    XXVIII, 
1289. 

6.  Manwerk,  Cor.-BL,  schweiz.  Aerzte,  Basel,  1881,  XI,  225-32. 

7.  RoECKL,   Amt.    Ber.   u.   d.   Versamml.   deutsch   Naturf.   u. 

Aerzte.  Freib.,  I,  Br.,  1884,  LVI,  127-130. 

OIDIUM  ALBICANS.— Oidium  is  frequently  found  in  the 
bronchia,  involving  the  mucous  membrane,  and  occasionally  in 
the  tissues  immediately  underlying  it.  It  is  usually  found  in 
clusters,  and  more  frequently  in  the  medium-sized  bronchia. 
It  may  be  primary  or  secondary,  and  involve  the  parenchyma 
of  the  lung. 

It  is  primary,  where  there  is  a  direct  opening  from  the  bron- 
chus into  cysts  or  abscesses;  secondary,  when  the  fungus  has 
first  involved  the  oral  or  bronchial  mucous  membrane  with  the 
existence  of  a  cyst,  abscess,  or  laceration  of  the  lung.  It  may 
also  be  secondary  by  the  extension  of  the  filaments  into  the  lung 
parenchyma,  when  the  fungus  has  developed  upon  the  smaller 
bronchia.  It  may  also  develop  upon  lung  tissue  recently  lac- 
erated from  any  cause,  when  the  fungus  is  present  anywhere  in 
the  respiratory  tract. 

( See  chapter  on  Odium  in  heart. ) 


Plate  LXXII. 


Experiment  on  Lungs,  No.  i6,  page  490. 


CHAPTER    XX 

ANIMAL  PARASITES  :— ECHINOCOCCUS,  PARAGONIMUS 
WESTERMANI,  CYSTICERCOSIS,  TRICHINA  SPIRALIS 

ECHINOCOCCUS. — Taenia  echinococcus  is  the  tape-worm  in 
the  dog,  and  its  larvae  enter  the  human  body  with  food  or 
water.  The  embryo  passes  through  the  wall  of  the  stomach, 
or  intestine,  to  develop  in  one  or  more  of  the  abdominal,  or 
thoracic  organs;  it  is  usually,  retroperitoneal,  when  the  peri- 
tonaeum is  involved.  It  may,  however,  be  within  either  the 
peritoneal  or  thoracic  cavities.  It  is  rarely  found  on  the  west- 
ern hemisphere,  but  is  quite  common  in  Iceland  and  Australia, 
especially  among  herders. 

Taenia  echinococcus  is  the  smallest  of  the  tape-worms ;  only 
the  last  segment  is  gravid  with  eggs.  Man  is  not  infected  by 
eating  meat  containing  the  hydatid,  because  it  is  only  the  em- 
bryo of  the  taenia  echinococcus  which  causes  disease  in  man. 
If  taken  into  the  body  in  the  mature  state,  the  hydatid  will  be- 
come encysted  without  injury  to  its  host.  Here  it  forms  its 
eggs,  and  is  thus  prepared  to  infect  any  animal  into  which  it 
gains  entrance.  If  the  hydatid  does  not  become  encysted 
it  is  either  digested,  or  passes  out  through  the  alimentary 
tract. 

Fifteen  per  cent,  of  all  cases  of  echinococcus  are  of  the  lung, 
and  are  usually  secondary  when  found  there.  Their  entrance 
into  a  vein  may  cause  instant  death.  Normal  fluid  in  the  cyst 
contains  mineral  salts  in  abundance,  but  no  albumen.  Occa- 
sionally the  fluid  contains  sugar.    The  cyst  may  be  destroyed  by 

449 


450  THE  SURGERY  OF  THE  LUNGS 

calcification,  or  it  may  rupture  into  the  pleura,  or  peritoneal 
cavity,  into  the  alimentary,  or  bronchial  tract,  into  the  uterus, 
Fallopian  tubes,  bladder,  kidneys,  or  ureters,  or  it  may  escape 
externally  at  any  point  through  the  thoracic  or  abdominal  walls. 
The  cyst  is  usually  solitary,  and  is  found  at  the  base  of  the 
lung.  It  may,  however,  occupy  the  entire  pleural  cavity.  The 
lung  is  usually  invaded  by  an  acephaloid  cyst,  which  does  not 
contain  echinococci. 

Historical  (1828-1903). — Todd  (1852)  reported  a  case  of 
hydatid  of  the  right  lung,  with  recovery  after  expulsion  of  the 
hydatid.  Bailey  (1861)  reported  a  case  treated  by  incision  of 
the  sac  after  internal  rupture.  Hearne  (1875)  collected  one 
hundred  and  forty-four  cases.  Of  these,  sixty-six  recovered 
and  eighty-two  died.  Forty-five  of  the  sixty-two  recoveries 
were  cured  by  the  bursting  of  the  cyst  into  the  air  passages. 
Five  were  punctured,  and  twelve  incised. 

McGillmary,  quoted  by  Greenfield  on  case  of  Hydatid  of  the 
Lung  {Clinical  Society  Transactions,  1877,  Volume  X,  p. 
103),  reported  sixty-five  cases,  of  which  nine  were  in  the  lung; 
he  says  that  no  portion  of  the  lung  seems  especially  prone  to  at- 
tack. Maydl  reported  four  cases  in  which  echinococci  were 
found  in  the  lung. 

Lehmann  (1882)  reported  eight  cases  of  cyst  in  the  lungs 
with  only  one  recovery,  and  that  by  operation.  De  Zouch's 
(1883)  case  of  suppurating  hydatid  of  the  lung  is  one  of  the 
few  reported  in  which  any  attempt  was  made  at  removal. 

Little  was  said  concerning  such  a  procedure  for  more  than 
a  century,  not  until  Thomas  (1885)  suggested  the  treatment 
of  cysts  by  the  establishment  of  large  openings  into  the  sac,  and 
subsequent  free  drainage.  Thomas  (1885)  collected  thirty-two 
cases  of  hydatid  of  the  lung  treated  by  incision,  with  twenty- 
five  recoveries.  He  says  there  is  a  mortality  of  fifty-four  per 
cent,  if  they  are  left  alone;  twenty-seven  per  cent,  when  punct- 
ure is  employed,  and  one  per  cent,  when  resection  and  incision 
are  resorted  to. 


Plate   LXXIII. 


Experiment  on  Lungs,  No.  i8,  page  490. 


ANIMAL  PARASITES  451 

Lopez  collected  thirty-six  cases  treated  by  incision  of  cyst, 
with  thirty  cures.  Madeliing  reported  nineteen  cases  of  hy- 
datid of  the  lung,  in  which  there  was  no  operation.  Ten  re- 
covered, three  were  relieved  by  opening  into  the  bronchus,  and 
six  died. 

Richeralle  (1888)  reported  a  case  and  Lorieux  furnished 
contributions  (1889)  to  the  study  of  hydatid  cysts.  Thomas 
( 1889)  reported  another  case,  that  of  a  large  echinococcus  cyst 
of  the  left  lung,  spontaneously  rupturing  into  the  bronchus,  and 
thus  causing  sudden  death.  Nicholson  (1890)  reported  a  case 
of  primary  hydatid  of  the  left  lung,  and  Danlos  gave  notes  on  a 
similar  case. 

Ferraud  (1890)  reported  a  case  of  hydatid  cyst,  opening 
spontaneously  into  the  bronchus.  Mackenzie  (1890-91)  re- 
ported a  case,  which  he  treated  by  paracentesis.  He  reported 
later  a  case  of  hydatid  of  the  lung,  which  proved  fatal,  by  rupt- 
uring into  the  bronchus  nine  hours  after  treatment  by  aspira- 
tion. (Transactions  Clinical  Society,  London,  1891-92,  XXV, 
215-220). 

Ord  and  Robinson  (1891)  incised  the  right  lung  in  a 
case  of  a  suppurating  hydatid  cyst,  and  drained,  but  the 
patient  died.  Marconnet  published  observations  on  hydatid 
cysts  in  the  lungs.  RevilHod  (1891)  published  a  paper 
on  echinococcus  infiltration  of  the  superior  lobe  of  the  right 
lung.  Pardy  (1891)  had  a  case  of  hydatid  of  the  lung 
bursting  into  the  pleura.  Thoracotomy  was  employed,  a  piece 
of  rib  removed,  and  the  patient  recovered.  Miers  reported  a 
case  of  hydatid  cyst  of  the  right  lung  rupturing  into  the 
bronchus. 

Bristowe  (1891)  treated  a  case  of  living  hydatid  of  the 
lung  by  aspiration,  followed  immediately  by  subcutaneous  em- 
physema; death  resulted  from  suffocation,  due  to  the  rush  of 
hydatid  fluid  into  the  bronchus.  Maydl  (1891)  collected  six- 
teen cases  treated  by  puncture.  Of  these  eleven  died,  five  from 
suppurating-  pleurisy,  six  from  puncture  alone,  making  a  total 


452  THE   SURGERY    OF   THE    LUNCzS 

mortality  of  sixty-nine  per  cent.  The  hydatid  may  extend 
from  the  pleura  into  the  lung. 

Laveran  (1892)  reported  a  case;  Clyhorn  and  Mackenzie, 
each  treated  a  case  of  hydatid  of  the  lung  by  paracentesis; 
Nuvoli  (1892)  treated  a  case  of  lung  hydatid  surgically; 
Bouilly  (1892)  employed  pneumonotomy  in  a  case  of  hydatid 
of  the  lung,  as  did  Netter  (1892-93).  Miralle  and  Scott 
(1893)  also  reported  cases. 

Trzebicki  reported  forty-five  operations.  There  were  thirty- 
seven  complete  cures ;  one  fistula  resulted ;  then  six  deaths,  and 
in  one  case,  the  result  was  not  known.  Sophianopoulos  and  De 
Villeneue  (1894)  published  reports  of  cases.  Todd  (1894) 
operated  upon  a  case  of  hydatid  of  the  lung,  and  Chepple,  Tatu- 
sescu,  Thomas,  and  Troquart  (1895),  each  reported  cases. 
Cooke  (1895)  published  short  notes  on  two  cases  of  suppurat- 
ing hydatid  of  the  lung,  simulating  phthisis,  which  were  cured 
by  operation.  Tuffier  (1896)  also  employed  pneumonotomy 
in  a  case  of  hydatid  of  the  lung,  and  Vespa,  Eberson,  and  Clerc 
( 1897)  increased  the  literature  of  the  subject  by  their  published 
reports. 

Geraud  (1897)  published  his  paper  on  diagnosis  of  hydatid 
of  the  lung,  and  Reed  ( 1897)  is  another  Australian  to  whom  we 
are  indebted  for  reports  on  this  subject. 

In  Milan  there  appeared  (1897)  a  report  on  a  case  of  pa- 
renchymatous suppurative  echinococcus  cyst,  and  Nicodemi,  an 
Italian,  reported  cases,  followed  by  Potherat  (1897),  of 
Paris.  Sterner  (1898)  published  his  operative  methods  in 
treating  echinococci  of  the  lungs.  Bacelli  and  Penrose  ( 1897) 
reported  cases  of  hydatid  cysts.  From  Australia,  which  has 
given  so  much  to  the  literature  on  this  subject,  came  Wood's 
report  of  three  cases.  His  fellow-countryman,  Hinder,  re- 
ported a  fatal  case  of  hydatid  of  the  lung.  Beck.  Pitzorno, 
Reid,  Nicodemi,  Lipari,  and  Piazza-Martini  (1898),  made 
contributions  to  the  literature  of  hydatids  of  the  lungs.  Davies 
treated  a  hydatid  cyst  of  the  left  lung  by  resection  of  a  rib, 
and  incision  of  the  cyst  wall. 


Plate  LXXIV. 


Experiment  on  Lungs,  No.  19.  page  490. 


ANIMAL    PARASITES  453 

Symptoms. — Often  there  is  no  pain,  only  a  bulging  of  the 
chest  wall.  It  may  be  confounded  with  solid  tumor  of  the  liver, 
but  it  must  be  remembered  that  a  cyst  in  the  liver  may  burst 
through  the  diaphragm  into  the  pleural  cavity.  In  such  a  case 
there  is  severe  pain  and  urgent  dyspnoea.  Death  may  result 
from  shock,  or  pleuritic  inflammation.  Such  a  state  of  affairs 
is  shown  by  sudden  expectoration  of  fluid,  generally  purulent 
or  bloody  in  character,  containing  echinococcus  vesicles,  entire 
or  in  fragments,  and  usually  followed  by  a  pneumothorax. 

Diagnosis. — Bulging  of  the  chest  wall,  and  circumscribed 
dulness  are  characteristic.  The  respiratory  sounds  are  absent. 
There  is  no  biliary  coloring  when  the  lung  alone  is  involved, 
but  this  occurs  if  the  liver  is  also  involved.  The  diagnosis  is 
doubtful  until  the  cyst  ruptures ;  then  the  microscope  is  the  only 
sure  means  of  diagnosis.  If  the  instrument  reveals  shreds  of 
membrane,  scolices,  or  booklets,  in  the  fluid  the  diagnosis  is 
certain.  Fluid  withdrawn  by  aspiration  will  contain  booklets, 
etc.,  but  at  times  it  is  necessary  to  supplement  the  work  of  the 
microscope  by  chemical  analysis. 

There  are  cases  in  which  all  means  of  diagnosis  result  in 
failure.  The  most  eminent  authorities  agree  that  only  forty 
per  cent,  of  all  cases  are  diagnosticated  during  life.  Devine 
says  that  two-thirds  of  lung  cases  die  when  left  to  themselves. 
The  growth  is  very  slow,  ten  to  fifteen  years  being  the  average 
duration.  As  it  is  not  malignant,  and  seldom  painful,  patients 
do  not  seek  aid ;  for  this  reason  there  are,  doubtless,  many  more 
cases  than  the  published  statistics  would  lead  us  to  suppose. 

Treatment — Those  who  have  had  the  most  experience  in 
treating  this  disease  claim  that  it  is  not  amenable  to  internal 
medication.  Some  writers  state  that  nitrate  of  silver,  ferric 
sulphide,  iodine,  carbolic  acid,  or  bichloride  of  mercury  taken 
internally,  or  injected  into  the  cavity  have  been  beneficial.  Also, 
that  small  doses  of  arsenic  will  prevent  the  eruption  of  potas- 
sium iodide,  which  is  much  used  in  treating  this  disease. 
Tuberculin,  injected  as  in  tuberculosis,  has  also  been  beneficial. 


454  THE   SURGERY   OF   THE    LUNGS 

The  majority  of  writers  agree  that  surgery  offers  the  surest  and 
safest  mode  of  treatment. 

When  it  has  been  deemed  best  to  resort  to  surgery,  divide 
the  ribs  posteriorly,  and  Hgate  the  bleeding  points.  The  cav- 
ity once  located,  the  finger  may  then  be  introduced  through 
the  lung  into  the  cyst  wall.  The  mother  cyst  is  to  be  grasped 
with  the  forceps  and  delivered.  If  ruptured  in  this  attempt, 
irrigation,  which  should  always  be  resorted  to,  will  probably  de- 
liver the  daughter  cysts.  The  subsequent  treatment  should  be 
as  for  an  open  chest  wound. 

"  Prevention  is  better  than  cure,"  applies  with  special  force 
to  this  disease.  The  experience  of  Iceland  is  that  it  is  neces- 
sary to  exclude  dogs  from  those  localities  in  which  their  faeces 
may  contaminate  the  food  or  drink,  not  only  of  man,  but  even 
of  sheep  and  cattle;  for  it  is  probable  that  cattle  are  infected 
chiefly  by  the  deposit  in  their  pastures  of  the  faeces  of  infected 
dogs,  or  by  their  drinking  water  thus  contaminated.  Neither 
should  dogs  be  allowed  to  eat  the  refuse  of  viscera  of  dead  or 
slaughtered  animals,  or  in  fact,  any  uncooked  flesh. 

BIBLIOGRAPHY 

ToDD,  Medical  Times  and  Gazette,  London,  1852,  n.  s.,  IV,  1-3. 

LoRiEUX,  Bordeaux,  1889,  No.  36. 

Thomas,  Aiistralas.  Medical  Gazette,  Sydney,  1889-90,  IX,  73. 

Nicholson,  Lancet,  London,  1890,  I,  747. 

Ferraud,   Bull.  Societe    Med.  de  VAnnee  1890,  Auxerre,   1891, 

XXXI,  65-69. 
Mackenzie,  St.  Thomas  Hospital  Rep.,  1890-91;  London,  1892, 

No.  XX,  336. 
Mackenzie,    Transactions    Clinical   Society,    London,    1891-92, 

XXV,  215-220. 
Ord   and    Robinson,    Transactions    Clinical   Society,   London, 

1891-92,  XXV,  125-128. 
Marconnet,  Prog.  Medical,  Paris,  1891,  2  s.,  XIII,  517-520. 


ANIMAL   PARASITES  45  5 

Revilliod,  Rev.  Med.  de  la  Suisse  Rom.,  Geneve,  1891,  XI,  129- 

133- 
Pardy,  Australia  Medical  Journal,  Melbourne,  1891;  n.  s.,  XIII, 

379-381- 
MiERS,  Medical  Gazette,  Sydney,  1891-92,  XI,  409. 
Bristowe,  Transactions  Clinical  Society,  London,  1891,  XXIV, 

73-78. 
Laveran,  Medecine  Mod.,  Paris,  1892,  III,  57-59. 
Clyhorn,  New  Zealand  Medical  Journal,  Dunedin,  1892,  V,  169. 
Mackenzie,  Lancet,  London,  1892,  I,  871. 
NuvoLi,  Gazz.  di  Roma,  1892,  XVII,  241-246. 
BouiLLY,  Bull,  et  Mem.  Societe  de  Chirurgie,  Paris,  1892,  n.  s., 

XVIII,    589. 
Netter,  Bull,  et  Mem.  Soc.  de  Med.  d.  Hop.,  Paris,  1892,  3  s.,  IX, 

613-622. 
Netter,  Bull,  et  Mem.  Soc.  de  Chirurgie,  Paris,  1893,  n.  s.,  XIX, 

389-394. 
MiRALLE,  Gaz.  d.  Hop.,  Paris,  1893,  LXVI,  105-113. 
Scott,  Australas.  Med.  Gaz.,  Sydney,  1893,  XII,  142-144. 
SoPHiANOPOULOS,  Galeno,  Athens,  1894,  Kd.,  315-319. 
De  Villeneue,  Atti  d.  Assn.  Med.  Lomb.,  Milano,  1894,  105-110. 
Todd,  Intercol.  Quar.  Jour.  Med.  and  Surg.,  Melbourne,  1894,  I, 

259-261. 
Chepple,  New  Zealand  Medical  Journal,  Dunedin,  1895,  VIII, 

179-184. 
Tatusescu,  Spitalul  bucuresci,  1895,  -^V,  44-46. 
Thomas,  Revue  Medicale  de  la  Suisse  Rom.,  Geneve,  1895,  XV, 

337-340. 
Torquart,  Journal  de  Med.,  Bordeaux,  1895,  XXV,  549-561. 
TuFFiER,  Association  Franc,  de  Chirurgie,  Paris,  1896,  X,  389- 

391- 
Vespa,  Bull,  di  Soc.  Lancissiana  d*  Osp.  di  Roma,  1894,  1895, 

XIV,  p.  26. 
Eberson,  Niederl.   Tidjdschar.  v.  Geneesk.,  Amsterdam,   1897, 

2  r.,  XXXIII,  d.  i.,  331-345. 
Clerc,  Bull.  Societe  Anat.,  Paris,  1897,  LXXII,  541-543. 


456  THE   SURGERY   OF   THE   LUNGS 

Geraud,  Bull.  Med.,  Paris,  1897,  XI,  845. 

Reed,  Intercol.  Med.  Journal,  Melbourne,  1897,  II,  608-611. 

Gazette  d'Osp.,  Milano,  1897,  XVIII,  1423. 
NicoDEMi,  Gazette  d'Osp.,  Milano,  1897,  XVIII,  556-568. 
Protherat,  Rev.  de  Chirurgie,  Paris,  1897,  XVII,  1028. 
Sterner,  Centrbl.  }.  Chirurgie,  1898,  XXV,  23. 
PoTHERAT,  Association  Franc,  de  Chirurgie,  Paris,  1897,  XI,  363- 

366. 
Bacelli,  Suppl.  d.  Policlin.,  Roma,  1897-98,  IV,  1 205-1 207. 
Penrose,  Lancet,  London,  1898,  II,  992. 
Wood,  Intercol.  Med.  Journal,  Melbourne,  1898,  III,  475-482. 
Hinder,  Australas.  Med.  Gaz.,  Sydney,  1898,  XVII,  348. 
Beck,  Journal  American  Medical  Association,  1898,  XXX,  i,  1238. 
PiTZORNO,  Gaz.  d'Osp.,  Milano,  1898,  III,  522. 
Reid,  Intercol.  Med.  Journal,  Melbourne,  1898,  III,  522. 
Nicordeni,  Practice  Firenze,  1897-98,  III,  71,  104,  129. 
LiPARi,  Gaz.  d' Osp.,  Milano,  1898,  XIX,  1573. 
Piazza-Martini,  Con.,  XIII,  Observations,  Palermo,  1898,  p.  74. 
FRAN9AIS,  H.,  Bull,  et  Mem.  Soc.  Anat.,  Paris,  1900,  II,  384. 
Sainton,  P.,  Rev.  de  Therap.  Med.-Chir.,  Paris,  1900,  LXVII, 

475-478. 
Palleri,  G.,  Gazz.  Med.  de  Marche,  1900,  VIII,  No.  51. 
Halipre,  Echo  Med.,  Toulouse,  1900,  XIV,.  126-130. 
Halipre,  Normandie  Med-,  Rouen,  1900,  XVI,  62. 
Parascandolo,  Clin.  Med.,  Pisa,  1900,  VI,  185-187,  193-197. 
Zambra,  Semana  Med.,  Buenos  Aires,  1900,  VII,  458-461. 
Schreckhaase,  Inaug-Diss.,  Griefswald,  1900,  Juli. 
Sainton,  P.,  Rev.  de  Therap.  Med.-Chir.,  Paris,  1900,  LXVII, 

475-478. 
Crouchet  et  Fauquet,  Jour,  de  Med.  de  Bordeaux,  1900,  XXX, 

III. 
Loi,  C,  Riforma  Med.,  Palermo,  1900,  III,  305. 
Caeser,  J.,  Lancet,  London,  1900,  II,  1872-73. 
JosiAS,  A.,  Bull,  et  Mem.  d'Hop.,  Paris,  1901,  XVIII,  436-441. 
Foucher,  a.  L.,  Lille,  1901,  68  p. 
Cassuto,  E.,  Bull.  Hop.  civ.  Franc  de  Tunis,  1902,  X,  117-123. 


Plate  LXXV. 


Experiment  on  Lungs,  No.  20.  page  491. 


ANIMAL   PARASITES  457 

GiARRE,  C,  Un  caso  di  cisti  voluminosa  da  echinococco  del  pol- 
mone  deatro  in  bambina  di  7  anni  curato  coUa  estirpazione. 
Riv.  crit.  di  Clin.  Med.,  Firenze,  1902,  III,  6. 


PAKAGONIMTJS  WESTERMANI — This  distoma  is  a  trema- 
tode,  indigenous  to  Asia,  found  in  China  and  Corea,  and  espe- 
cially prevalent  in  Formosa  and  Japan,  where  it  has  never, 
however,  been  found  in  the  hog.  It  is  found  in  both  man 
and  domesticated  animals,  such  as  the  dog,  cat,  and  hog,  in 
the  United  States, 

Paragonimus  Westermani  usually  attacks  the  lungs  by  the 
formation  of  nodules,  generally  near  their  roots.  As  a  rule, 
the  nodules  are  occupied  by  two,  probably  male  and  female, 
parasites.  The  brain  has  been  found  infested  by  them,  in  which 
case  the  cortical  substance  is  involved,  causing  epilepsy.  Man- 
son,  who  first  described  this  disease,  terms  it  parasitic  haemop- 
tysis. It  is  very  common  in  Japan ;  we  owe  most  of  our  knowl- 
edge of  it  to  the  Japanese  physicians.  Baelz  said  that  in  one 
village  in  Japan  nearly  all  the  inhabitants  harbored  lung  worms. 

Historical. — Kerbert  (1878)  described  a  distoma  that  had 
been  found  in  a  Royal  Bengal  tiger.  This  is  one  of  the  earliest 
published  reports.  Ward(i894)of  the  University  of  Michigan, 
reported  that  a  parasite  discovered  by  Professor  Kellicott,  of 
the  University  of  Ohio,  was  identical  with  that  of  Kerbert. 
The  United  States  Bureau  of  Animal  Industry  reported  fifty 
cases  in  the  dog,  found  in  Ohio.  The  sixteenth  report  gives  a 
number  of  instances  in  which  it  was  found  in  the  hog.  This 
same  report  contains  a  resume  of  the  literature  on  the  subject, 
and  it  has  been  largely  drawn  upon  for  the  following  matter. 

In  Japan  and  Formosa  from  fifteen  to  twenty-five  per  cent, 
of  the  inhabitants  suffer  from  haemoptysis  caused  by  this  para- 
site. It  is  often  confounded  with  tuberculosis,  since  it  can 
only  be  diagnosticated  by  aid  of  the  microscope.  It  is  not 
found  in  the  very  young  or  in  the  very  old.     Some  of  the  au- 


458  THE  SURGERY  OF  THE  LUNGS 

thorities  state  that  persons  of  strong  constitutions  are  more  sub- 
ject to  this  disease  than  others.  It  has  been  found  in  persons 
following  various  pursuits  and  occupying  various  stations  in 
life.  In  fifty-nine  cases  the  ages  were  known;  of  these,  forty- 
five  were  between  eleven  and  thirty.  Of  sixty-six  cases  of 
known  sex,  fifty-eight  were  males,  and  eight  females. 

This  parasite  has  been  found  in  the  same  domesticated 
animals  in  this  country  as  in  Japan.  It  is  also  now  found  in 
man  in  this  country,  having  been  brought  here  by  soldiers 
returning  from  Asia. 

Father  Clos,  S.J.,  who  has  recently  returned  from  the  Phil- 
ippines, says  that  he  has  observed  numerous  cases  of 
haemoptysis  among  the  natives. 

It  should"  be  remembered  that  infection  of  the  lung  may  be 
complicated  by  infection  of  the  brain,  liver,  or  other  organs. 

Symptoms,  Diagnosis,  and  Treatment. — The  sputa  are  similar 
to  those  of  pneumonia,  of  a  dirty  brown  or  red  color,  due  to 
the  microscopic  worm  eggs.  Spitting  of  blood  is  common ;  in- 
termittent cough  is  common  but  not  constant.  The  only  con- 
stant factor  is  the  presence  of  the  eggs  in  the  sputum.  As  much 
as  ten  or  twelve  ounces  may  be  expectorated  daily,  containing 
thousands  of  eggs.  Usually  the  disease  makes  slow  progress, 
and  at  the  end  of  several  years,  six,  eight,  or  ten,  the  patient  is 
no  worse.  This  form  of  haemoptysis  is  seldom  associated  with 
other  serious  lung  troubles. 

Physical  examination  reveals  nothing  abnormal,  except  in 
the  worst  cases.  The  temperature  is  normal,  or  only  slightly 
elevated.  Frequently  there  is  slight  oedema.  Patients  de- 
scribe a  sensation  in  the  chest  of  oppression,  or  of  heat,  or  mere 
irritation.  Occasionally,  there  are  neuralgic  pains  in  the  chest. 
The  sufTerer  may  get  out  of  bed,  and  months  pass  before  a  re- 
lapse occurs.  But  the  relapse  will  come  sooner  or  later.  This 
happens  over  and  over  again,  until  the  patient  is  worn  out. 

No  benefit  has  been  derived  from  medicine  in  treating  this 
disease.     General  treatment  is,  undoubtedly,  useful ;  but  rest 


Plate  LXXVI. 


Experiment  on  Lungs,  Xo.  21,  page  491. 


ANIMAL   PARASITES  459 

and  good  food  are  essential.     Exertion  aggravates  all  the  bad 
symptoms. 

Yarnagiwa  thinks  surgery  might  be  tried  if  the  exact  loca- 
tion of  the  more  superficial  cysts  could  be  learned. 

BIBLIOGRAPHY 

CoBBOLD,  T.  S.,  Trans.  Linn.  See.  London,  XXII  (1856-59),  pp. 

363-366,  Tab.  LXIII. 
Baelz,  Lancet,  London,  1880,  II,  pp.  548-49. 
Baelz,  Uber  parasitare  Hamoptoe.     Central,   f.  d.  med.  Wiss., 

XVIII  (39),  25  Sept.,  pp.  721-722. 
Kerbert,  Zool.  Anz.,  I,  pp.  271-273. 
Manson,  Med.  Times  and  Gaz.,  London,  July  8,  1882. 
Yamagiwa,  K.,  Arch.  f.  Path.  Anal.  u.  Phy.  u.  f.  Klin.  Med., 

CXIX  (2),  447-460.    Ibid.,  ditto,  CXXVII,  3  Hft.,  446-456. 
Railliet,  Le  Naturaliste,  XII,  142-143. 
Yamagiwa  and  Inouye,  Zeit.  Med.  Geo.  Tokyo,  IV,  21  Hft.  (Art. 

No.  7),  1890. 
Weber,  Tijdsch.  der  Nederl.  Dierk.  Vereen.,  2  s..  Ill,  2  versl.  pp. 

LXXXIII-LXXXIV. 
Blanchard,  R.,  Note  sur  quelques  vers  parasites  de  I'homme. 

Compt.  Rend.  Soc.  Biol.,  Paris,  9  s..  Ill,  pp.  604-615,  1891. 
Braun,  Max,  Vermes  (Bronn's  Klassen  und  Ordnungen  desThier 

Reichs,  Bd.  IV,  1892,  Lief.  18-27,  PP-  561-816). 
Stiles,  Bull.  Johns  Hopkins  Hosp.,  V,  57-58. 
Ward,  Vet.  Mag.,  II,  pp.  87-89.     Ibid.,  Med.  News,  Philadelphia, 

LXVI,  pp.  236-239. 
Blanchard,  R.,  Traite  de  Pathologie  Generale  (Bouchard),  II 

pp.  649-932. 
Jaksch,  R.  von,  and  Cagney,  Jas.,  Clinical  Diagnosis,  London, 

1897. 
Simon,  Manual  of  Clinical  Diagnosis,  2nd  ed.,  Philadelphia  and 

New  York,   1897. 
Looss,  A.,  Zool.  Jarh.  Abt.  }.  Syst.,  Gcorg.  u.  Biolog.  d.  Th.,  XIL 

pp.    521-784,    1899. 


460  THE  SURGERY  OF  THE  LUNGS 

Braun,  Max,  Uber  Clinostomun  Leidy.     Zool.  Anz.,  XXII   (602) 

November  27th,  pp.  484-488,  1899. 
Stiles  and  Hassal,  Sixteenth  Annual  Report,  Bureau  of  Animal 

Industr)',  U.  S.  Dept.  Agr.,  Washington,  D.  C,  1900. 

PTTLMONAP-Y  CYSTICERCOSIS — Cysticercosis  is  a  para- 
sitic disease  caused  by  the  presence  of  entozoons.  These  ento- 
zoons,  known  as  cysticerci,  are  the  larvae  of  various  species  of 
taeniae  (tapeworms).  Before  their  identity  as  embryonic 
forms  of  tapeworms  was  discovered,  the  cysticerci  were  con- 
sidered to  be  a  distinct  genus  of  the  order  Cestoda.  Hence, 
the  many  names  which  have  been  given  to  them.  The  cysticerci 
are  the  spherical  or  oval  embryos  from  which  the  head  (scolex) 
of  the  tapeworm  develops.  It  is  not  the  most  primitive  form 
of  the  tapeworm,  as  it  is  developed  from  another  embryonic 
form. 

Many  of  the  animals  which  are  found  about  the  habitations 
of  men  harbor  the  various  embryos  of  the  tapeworm.  Thus  the 
embryos  gain  entrance  into  a  human  host  to  develop  into  the 
mature  strobila,  or  fully  developed  tapeworm.  The  cysticerci 
are  found  in  all  the  domesticated  animals  whose  flesh  is  used 
for  food.  The  use  of  uncooked  meat ;  soiling  of  the  hand  by 
working,  or  handling  dirt,  etc.,  in  which  the  faeces  of  these  ani- 
mals, or  of  fowls  may  have  been  deposited,  are  fruitful  sources 
of  infection.  So,  too,  persons  who  harbor  tapeworms,  or  from 
whom  a  tapeworm  may  have  been  expelled,  become  self-infected 
through  the  hands  coming  in  contact  with  the  anus  in  sleep, 
from  eggs  which  may  escape  per  anum  and  stick  to  the  under- 
garments, etc. 

The  cysticerci  have  been  known  to  invade  all  parts  and 
organs  of  the  human  body.  Cysticercosis  of  the  lungs,  how- 
ever, is  comparatively  rare,  but  by  no  means  unknown,  as  wit- 
ness the  reports  of  cases  (see  bibliography).  It  is  quite 
probable  that  some  of  the  cases  diagnosticated  and  reported  as 
hydatid  cysts  of  the  lungs,  have  been,  in  reality,  cases  of  pul- 
monary cysticercosis.     A  mistake  of  this  character  could  be 


ANIMAL    PARASITES  46l 

made  easily,  since  the  dog  tapeworm  (taenia  echinococcus)  is 
the  smallest  tapeworm  known,  and  greatly  resembles  certain 
kinds  of  cysticerci. 

Measly  pork  or  beef  is  caused  by  cattle  and  hogs  being  in- 
fected with  cysticerci,  which  have  become  encysted.  The  cysts 
can  be  seen  with  the  naked  eye  in  salt  pork  or  corned  beef  when 
dry;  but  they  become  invisible  when  the  meat  is  damp.  In 
meat,  these  cysts  appear  as  small,  white,  calcareous  spots,  about 
the  size  of  a  pin-head.  While  in  man,  the  cysts  range  in  size 
from  that  of  a  pin-head  to  that  of  an  adult  head. 

The  lungs  may  become  infected  by  carrying  soiled  hands  to 
the  mouth ;  by  cysts  of  infected  meat  being  broken  in  the  mouth 
and  the  cysticerci,  thus  set  free,  penetrating  the  oesophagus; 
and  by  the  migration  of  cysticerci  from  other  organs  or  parts 
of  the  body. 

The  author  found  cysticerci  in  the  sputum  and  urine  of  a 
woman  fifty-five  years  of  age,  under  the  care  of  Dr.  W.  E. 
Langdon.  She  resided  on  a  farm  and  cared  for  several  kind  of 
fowl. 

Symptoms,  Diagnosis,  and  Treatment. — The  cysts,  themselves, 
rarely  give  any  trouble,  but  the  increase  in  size  may  produce 
grave  complications,  mechanically.  If  the  cysticerci  are  free, 
or  if  they  escape  from  the  cyst,  many  grave  complications  will 
result. 

The  symptoms  of  pulmonary  cysticercosis  present  nearly  the 
same  clinical  picture  as  hydatid  cysts  of  the  lungs.  In  addition 
there  are  frequent  asthmatic  attacks,  emaciation,  loss  of  appe- 
tite, etc.  A  microscopical  examination  afifords  the  only  means 
of  making  a  positive  diagnosis.  At  times  the  microscopical  ex- 
amination may  need  to  be  supplemented  by  a  chemical  analysis, 
but,  generally,  a  microscopical  examination  is  sufficient ;  eggs, 
encysted  embryo,  heads,  etc.,  being  found  in  the  fluid.  The 
microscope  should  be  used  as  a  regular  routine  procedure  in  all 
clinical  examinations.  Very  often  a  chemical  analysis  fails  to 
reveal  the  most  important  thing. 


462  THE   SURGERY   OF  THE   LUNGS 

A  bottle  of  urine,  and  also  of  sputum,  were  left  at  one  time 
for  examination.  As  is  the  usual  practice  in  the  office,  the  urine 
was  first  placed  undc.  the  microscope.  At  first,  there  were  only- 
evidences  of  diabetes,  and  intravesicular  inflammation.  A 
chemical  analysis  would  have  confirmed  this  diagnosis,  but  a 
little  further  search  discovered  the  true  cause  of  the  disease  and 
explained  all  the  clinical  symptoms.  For,  there,  in  plain  view, 
were  two  cysticerci.  Here  were  evidences,  which  vitiated  the 
inductions  previously  made. 

It  is  claimed  that  no  medicine  will  do  any  good  in  certain 
forms  of  cysticercosis.  But  in  case  of  pulmonary  cysticercosis 
some  hold  that  arsenic,  iodides,  etc.,  may  be  effective.  All, 
however,  agree  that  when  the  cysticerci  are  accessible,  the  sur- 
geon's knife  furnishes  the  most  reliable  means  of  treatment. 

BIBLIOGRAPHY 

Ramesay,  "  EXfilvdXoyia  or,  Some  Physical  Considerations  of  the 
Matter,  Origination,  and  Several  Species  of  Worms,  Macera- 
ting and  Direfully  Cruciating  Every  Part  of  the  Bodies  of 
Mankind,  of  all  Ages  and  Constitutions;  whereby  it  doth 
probably  appear  to  be  an  Epidemical  Disease,  killing  more 
than  either  the  Sword  or  Plague.  Together  with  their  Various 
Causes,  Signs,  Diagnostics,  Prognostics,  the  Horrid  Symptoms 
by  them  Introduced,  as  also  the  Indications  and  Methods  of 
Cure.  All  of  which  is  Medicinally,  Philosophically,  Astro- 
logically,  and  Historically  Handled,"     London,  1668. 

Lewald,  De  cysticercarum  in  taeniis  metamorphosi  pascendi 
expcrimcntis  in  Institute  physiologico,  Vratislar.  Berlini, 
1852. 

LANKESTER-KtJCHENMEiSTER,  On  animal  and  vegetable  parasites 
of  the  human  body.     London,  1857. 

Passot,  Note  sur  le  t^nia,  et  sur  I'cxpulsion  par  I'dmetiquc,  d'un 
de  ces  parasites  dans  un  cas  dc  pneumonic.  Gaz.  med.  de 
Lyon,  i860,  XII,  131-134. 


Plate  LXXVII. 


Experiment  on  Lungs,  No.  22.  page  491. 


ANIMAL   PARASITES  463 

Carter,  On  a  Bisexual  Ncmatoid  Worm  which  Infests  the  Com- 
mon Housefly  (Musca  domcstica)  in  Bombay.     Trans.  Med. 

and  Phy.  Soc,  Bombay  (1860-61),  n.  s.,  VI,  app,  pp.  Ixii- 

Ixvi. 
RoELKER,  On  Taenia  and  Cysticercus.     Cin.  Lancet  and  Obser., 

1863,   VI,   329-339. 
Smith,  Human  entozoa,  London,  1863. 
Oldham,  On  a  Cystic  Parasite  Infecting  Sheep.     Indian  Med. 

Gaz.,  Calcutta,  1873,  VIII,  204. 
CoBBOLD,  The  Internal  Parasites  of  our  Domesticated  Animals. 

London,  1873. 
Lesbini,  Des  larves  parasites  trouves  chez  I'homme.     Acta  Acad. 

nac  de  cien.  exact.,  Buenos  Aires,  1878,  III,  41-63. 
Hayem,  Lesion  parasitaire  simulant  les  tubercules,  etc.     Bull.  Soc. 

Anat.  de  Paris,  1875,  L,  756. 
Laboulbene,  Sur   les   tenias,  les  ecchinocoques,  et    les    botrio- 

cephales  de  I'homme.     Bull,  et  mem.  d'hop.  de  Paris  (1876), 

1877,  2  s.,  XIII,  38-82. 
Rochefortaine,   Pentastome   denticule   provenant   du   poumon. 

Compt.  Rend.  Soc.  deBiol.  de  Paris,  1876,  Paris,  1877,  ^  s.,  Ill, 

261. 
Leuckart  (Trans,  by  Hoyle),  The  Parasites  of  Man.    Edinburgh, 

1886. 
Rougier-Grangeneuve,  Maladies  vermineuses  et  maladies  in- 

fectes.     Bordeaux,  1880. 
PiANA,  Di  un  nuova  specie  di  tenia     .     .     .     e  di  un  nuova  cisti- 

cerco.     Mem.  Accad.  d.  c.  d.     Inst,  di  Bologna,  1880. 
Gibbes,  Nematode  worms  in  the  lungs,  etc.     Trans.  Path.  Soc, 

London,  1883. 
MoNiEZ,  Sur  les  cysticerques  des  tenias.     Rev.  Internal,  de  sc.  bioL, 

Paris,  1880,  V,  135-152. 
Remmert,  Cysticercus  cellulosae.     Berlin,  1893. 
Kuss,  Diagnostico  de  la  cisticercosis  en  la  especie  humana.     Arch. 

de  la  Policlin,  Habana,  1897,  V,  51-58. 
Ricketts,  B.  M.,  and  Langdon,  W.  E.,  Cysticercus  in  the  Lung 

and  Urinary  Bladder. 


N 


464  THE  SURGERY  OF  THE  LUNGS 

TRICHINA  SPIRALIS.— Trichina  Spiralis  is  a  nematode 
worm  found  principally  in  the  pig,  but  occasionally  in  man 
after  the  ingestion  of  pig  meat.  The  parasite  perforates  the 
intestinal  wall,  and  enters  the  various  muscular  tissues  there- 
after. It  becomes  encapsulated  chiefly  in  the  diaphragm,  mus- 
cles of  the  back,  shoulder,  neck,  eye,  larynx,  tongue,  and  oc- 
casionally the  muscles  of  the  lung.  The  cyst  is  ovoid  in  shape, 
at  first  transparent,  becoming  opaque  and  ultimately  calcifying. 
It  is  coiled,  and  the  female  is  larger  and  more  numerous  than 
the  male. 

Treatment. — The  same  surgical  measures  are  applicable  to 
all  lesions  produced  by  parasites,  whether  fungdid,  animal  or 
bacilli.  A  positive  diagnosis,  even  with  the  microscope,  cannot 
always  be  made.  Trichinae  are  said  to  be  especially  difficult  to 
detect.  The  most  important  features  in  all  are  the  complete 
removal  and  evacuation  of  the  cyst,  with  annihilation  of  its 
occupant.  In  all  cases  the  resection  of  one  or  more  ribs  is 
necessary,  together  with  fixation,  if  possible,  of  the  cyst  wall  to 
the  thoracic  wall,  at  a  point  corresponding  to  the  greatest 
prominence  of  the  cyst.  This  is  to  be  done  whether  it  occupies 
the  anterior  or  posterior  surface  of  the  lung,  or  its  base  or  apex. 

If  the  mediastinal  wall  should  be  involved,  the  sternum 
should  be  sufficiently  removed  to  permit  of  free  drainage 
through  the  mediastinal  space.  The  cavity,  in  either  event, 
should  be  thoroughly  irrigated  with  sterilized  water ;  great  care 
being  exercised  to  see  that  all  debris  is  removed.  When  this 
is  done,  the  inner  wall  of  the  cavity  should  be  brushed  with  a 
saturated  solution  of  carbolic  acid,  iodine  or  formaldehyde ;  and 
the  cavity  packed  with  gauze,  the  end  of  which  should  be  se- 
cured externally.  The  amount  to  be  used  must  be  governed  by 
the  necessity  of  controlling  bleeding.  The  frequency  of  chang- 
ing the  packing,  and  the  amount  to  be  used  should  be  governed 
also  by  necessity. 

If  the  cyst  wall  cannot  be  fixed  to  the  chest  wall,  one  should 
not  hesitate  to  incise  it  freely  and  expose  it  through  the  pleural 


ANIMAL   PARASITES  465 

cavity ;  care  being  taken  to  have  perfect  drainage  at  the  lowest 
point  in  the  cavity.  If  the  bronchus  has  been  opened  by  rupt- 
ure of  the  cyst,  firm  packing  of  the  cyst  cavity  will  be  the  more 
essential,  as  such  a  rupture  in  connection  with  an  external  open- 
ing, might  cause  partial  or  complete  apneumatosis  of  one  or  all 
of  the  lobes  of  the  lung  involved. 

BIBLIOGRAPHY 

Hennen,  Principles  of  Military  Surgery,  1829,  p.  372. 

Larrey,  Clinique  Chirurigicae,  1832,  II,  195. 

Hastings  and  Storks,  Medical  Times  and  Gazette,  December, 
1844. 

Norman,  Prov.  Med.  Journal,  1844. 

Jones  and  Sieveking,  Manual  of  Pathological  Anatomy,  ist 
American  Ed.,  Philadelphia,   1854. 

Velpeau,  a.  a.  L.  M.,  "Operative  Surgery,"  3  Volumes,  New 
York,  1856. 

McDonnell,  Dublin  Quar.  Journal,  1864,  XXXVIII,  p.  205. 

Flint,  Austin,  Principles  and  Practice  of  Medicine,  3d  Edition, 
Philadelphia,  1868. 

Fraentzel,  Krankheiten  d.  Pleura.     Ziemssen's  Handbuch,  1875. 

Erichsen,  John  Eric,  Science  and  Art  of  Surgery  from  7th  Eng- 
lish Edition,   Philadelphia,    1878. 

HiRD,  Medical  Times  and  Gazette,  1878,  II,  p.  514. 

Montar-Martin,  Etude  sur  les  Pleuresies  Hemorrhagiques,  Neo- 
membrane,  etc.,  Paris,  1878,  p.  162. 

Woodward,  J.  J.,  Medical  and  Surgical  History  of  the  War  of 
the  Rebellion,  ist  Issue,  Washington,  1879. 

Gross,  Sam.  D.,  System  of  Surgery,  6th  Edition,  2  Volumes, 
Philadelphia,  1882. 

Holmes,  T.,  System  of  Surgery,  ist  American  Edition  from  2d 
Enghsh  Edition,  Philadelphia,  1882. 

CuRNOW  AND  KiDD,  Path.  Soc.  Trans.,  1883,  1885. 

Roberts,  Fred.  T.,  Theory  and  Practice  of  Medicine,  Fifth  Amer- 
ican Edition,  Philadelphia,  1884. 


466  THE  SURGERY  OF  THE  LUNGS 

Walsham,  Medical  Times  and  Gazette,  1884,  I,  p.  452. 

Penzoldt,  Verhandl.  des  Congr.  }.  Inn.  Med.,  1885-86,  p,  58. 

Hamilton,  F.  H.,  Principles  and  Practice  of  Surgery,  New  York, 
3d  Edition,   1886. 

Gray,  Henry,  Anatomy,  New  American  Edition  from  nth  Eng- 
lish, Philadelphia,  1887. 

Wyeth,  John  A.,  Text  Book  on  Surgery,  New  York,  1887. 

Wheelhouse,  British  Medical  Journal,  1887,  II,  1141. 

Neisser,  Die  Echino-Kokkenkrankheit,  Berlin,  1887. 

Jacobson,  W.  H.  a..  Operations  of  Surgery,  Philadelphia,  1889. 

Agnew,  D.  Hays,  Principles  and  Practice  of  Surgery,  2d  Edition, 
Philadelphia,  1889. 

Senn,  Nic,  Principles  of  Surgery,  Philadelphia,  1890. 

James,  Trans.  Med.  Chir.  Soc,  Edinburgh,  1890-91. 

KoLiSKO,  Wien.  KHn.  Wochenschr.,  1891,  p.  665. 

Heydenreich,  Semaine  Med.,  1891. 

Treves,  Fred,  Operative  Surgery,  Philadelphia,  1892. 

Delafield  and  Prudden,  Pathological  Anatomy  and  Histology. 
New  York,  4th  Edition,  1892. 

Keen  and  White,  American  Text-Book  of  Surgery,  Philadelphia, 
1892. 

Harris,  Intrathoracic  Growths,  St.  Barth.  Hasp.  Reports,  1892, 
Vol.  XXVIII,  p.  73. 

BoYCE,  Journal  Path.  Bad.,  October,  1892. 

Schlange,  Zur  Prognose  der  Aktinomycose,  Deutsch.  Ges.  }. 
Chir.,  1892. 

Pitt,  Lectures  on  the  Surgery  of  the  Air-passages  and  Thorax  in 
Children.     Lancet,  October,  1893. 

Bramann,  Verhandl.  d.  Deutsch.  Ges.  f.  Chir.,  1893,  p.  114. 

Hale  and  Goodhart,  Clinical  Society's  Transactions,  1893. 

Jaffe,  Transactions  Path.  Society,  London,  1894. 

Senn,  Nic,  Pathology  and  Surgical  Treatment  of  Tumors.  Phila- 
delphia, 1895. 

Warren,  John  Collins,  Surgical  Pathology,  Philadelphia,  1895. 

Dennis,  Fred.  S.,  System  of  Surgery,  Philadelphia,   1895. 

Semaine  Medicale,  February  6,  1895. 


Plate  LXXVIII. 


Experiment  on  Lungs,  No.  24,  page  491. 


ANIMAL   PARASITES  *  467 

RiEDiNGER,  Congress  Franf.  de  Chir.,  1895,  p.  99. 

LoCKWOOD,  Traumatic  Infection,  1895,  P-  23. 

Moore,  Dublin  Quar.  Journal,  XXXIX,  279. 

Beez,  liber  Seltenere  Vorkommnisse  bei  Necrose  und  Vereiterung 
von  Bronchial-druesen.     Jena,  1895. 

PoLAiLLON,  Affections  Chirurgicales  du  Tronc.     Paris,  1896. 

West,  Clinical  Society  Reports,  April,  1896. 

Murray,  Extensive  Resection  of  Ribs  for  Emphysema.  Annals 
of  Surgery,  May,  1896. 

Marie,  Lemons  de  Clinique  Medicale,  Paris,  1896. 

Tillmanns,  Dr.  Her.,  The  Principles  of  Surgery  and  Surgical 
Pathology.     'New  York,  1897. 

Paget,  Stephen,  Surgery  of  the  Chest.    New  York,  1897. 

Wharton  and  Curtis,  Practice  of  Surgery.     Philadelphia,  1898. 

Sajous,  C.  E.  de  M.,  Annual  and  Analytical  Cyclopaedia  of  Prac- 
tical Medicine.     Philadelphia,    1 898-1 900. 

Surgeon-General  United  States  of  America.  Reports  for  1899 
and  1900. 

Deaver,  'John  B.,  Surgical  Anatomy.  Three  Volumes,  Phila- 
delphia, 1900. 

Stimson  and  Keyes,  Jr.,  Wounds  and  Injuries  of  the  Chest. 

Sajous's  Annual  and  Analytical  Cyclopaedia  of  Practical  Medicine. 
Vol.  VI,  1901. 

RuMPF,  Uber  Newbildungen  im  Mediastinum.     Freiburg. 


PLATES,  PART  II. 

Repair  of  Lung. 

Sutures. 

Dog's  Lungs,  in  situ  (Anterior  view). 

Dog's  Lungs,  in  situ  (Posterior  view). 

Sections  of  Dog's  Lungs  (7). 

Photos  of  dogs'  lungs    after  operation  (22). 


468 


EXPERIMENTAL  RESEARCH  ON  THE  LUNGS  OF 

THE  DOG. 

This  series  of  experiments  was  conducted  at  the  labora- 
tories of  the  University  of  Cincinnati  from  June  25  to  Sept.  i, 
1900,  for  the  purpose  of  demonstrating  how  far  surgical  inter- 
ference with  the  lung  could  be  carried,  and  also  to  establish  the 
best  technics  in  lung  surgery. 

Although  the  anatomy  of  the  lung  has  been  rather  exten- 
sively treated,  the  physiology  and  pathology  have  been  only 
considered  as  they  bear  directly  upon  the  surgery. 

The  author  takes  this  opportunity  to  thank  Drs.  J.  Stuart 
Wallingford,  T.  G.  Sellew,  and  his  student,  C.  T.  Souther,  for 
their  most  valuable  and  devoted  services. 

Fifty  dogs  were  used  in  conducting  these  experiments.  No 
abnormalities,  or  parasites  were  found  in  any  of  the  dogs. 
Neither  were  any  malignant  or  benign  growths  found.  Only 
one  dog  had  hernia,  and  that  was  ventral.  No  case  of  host- 
operative  hernia  developed.  One  hundred  and  sixty-five  dogs 
were  used  for  all  purposes,  and  none  of  the  above  conditions 
was  found.     Only  one  dog  had  tuberculosis  (No.  48). 

After  No.  5,  each  dog  was  thoroughly  scrubbed,  the  chest 
shaven,  and  skin  washed  with  turpentine.  Ether  was  invari- 
ably employed,  except  for  producing  death,  for  which  purpose 
chloroform  was  used.  No  antiseptics  were  used,  except  tur- 
pentine, which  was  applied  to  all  wounds,  after  the  incision  had 
been  closed  with  silkworm  gut.  Dressings  of  any  character 
were  discarded  after  dog  No.  5,  the  wounds  being  left  unpro- 

469 


470  THE   SURGERY    OF   THE   LUNGS 

tected.  Drainage  was  employed  in  only  one  case,  No.  i8, 
which  died  on  the  fifth  day,  from  infection. 

The  food  consisted  of  water,  bread  and  milk,  and  raw  beef. 
The  ages  and  weights  given  are  only  approximate. 

In  no  case  did  an  abscess  of  the  lung  follow  any  of  these 
operations. 


CHAPTER  XXI 
THE  LUNG  OF  THE  DOG 

EXPERIMENTAL    RESEARCH 

An  anterior  view  of  the  thoracic  organs  of  a  dog  shows  how 
nature  provides  protection  for  the  more  deHcate  and  vital  or- 
gans. The  heart  will  be  seen  surrounded,  and  overlapped  in 
part,  by  the  lobes  of  the  lungs.  The  right  upper  lobe  of  the 
lung  overlaps  the  entire  upper  portion  of  the  heart,  while  the 
left  upper  lobe  affords  like  protection  to  the  other  side.  The 
middle  lobes  too,  close  in  around  the  heart,  forming  a  natural, 
living,  air  cushion,  thus  warding  off  injuries  to  the  heart. 

The  right  lower  lobe  is  the  largest  lobe  of  a  dog's  lung,  while 
the  right  middle  lobe  might  be  taken  for  a  process  of  the  former. 

The  shape  of  the  butterfly  lobe  shows  why  it  received  its 
name. 

The  left  upper  lobe  overlaps  the  right  upper  lobe  for  a  short 
distance,  and  thus  aids  in  completing  the  air  cushion-like  pro- 
tection of  the  heart.  The  left  middle  lobe  overlaps  both  the 
upper  and  lower  lobes,  and  fills  in  the  space  between  the  two ; 
the  left  lobe  extends  downward  more  than  the  others. 

A  posterior  view  of  a  dog's  thoracic  organs,  in  situ,  is  also 
interesting. 

The  arrangement  and  connection  of  the  various  lobes  may 
be  very  clearly  comprehended.  The  thoracic  aorta  is  perfectly 
visible,  as  are  the  intercostal  branches,  which  are  seen  shooting 
off  in  pairs  at  regular  intervals.  Viewed  from  this  aspect,  the 
bronchial  gland  can  be  seen.     When  all  the  bronchial,  pul- 

471 


472  THE  SURGERY  OF  THE  LUNGS 

monary,  and  arterial  vessels  are  injected  with  a  solution  of 
starch,  aniline,  and  formalin,  the  thoracic  organs  will  assume 
and  retain  their  natural  shape  and  appearance,  after  removal. 
It  will  be  found  that  some  of  the  injected  material  will  escape, 
but  sufficient  material  will  remain  to  keep  the  organs  distended. 

Now,  if  the  lungs  be  viewed  from  a  posterior  aspect,  the 
thoracic  aorta,  the  great  pulmonary  veins,  the  bronchus,  in  situ, 
in  the  lung  tissue,  etc.,  can  be  seen  easily.  Such  an  ex- 
amination will  give  one  not  only  a  better  knowledge  of  the 
dog's  lung,  but  of  the  human  lung  as  well. 

The  plates  numbered  I  and  LVII  to  LXIII  show  the 
normal  appearance  of  the  dogs'  lungs,  while  plates  num- 
bered LXIV  to  LXXXVII  show  the  appearance  of  the  dogs' 
lungs,  after  the  various  operations  described  thereunder. 

These  experiments  proved  that,  in  case  of  a  dog,  the  middle 
of  the  right  upper  lobe  may  be  severed  by  throwing  a  kangaroo 
tendon  around  its  middle,  and  occluding  the  bronchial  lumen; 
the  inferior  lobe  of  the  right  lung  may  be  split,  and,  if  sutured 
at  once,  recovery  will  ensue.  A  dog  will  recover,  even  after  a 
piece  has  been  torn  from  a  lobe.  An  incision  may  be  sutured 
with  perfect  confidence.  An  entire  lobe  may  be  removed,  at 
least  in  case  of  traumatic  injury.  In  one  case,  the  inferior  lobe 
of  the  right  lung  was  removed  with  perfect  success ;  in  another, 
the  lower  half  of  the  inferior  lobe  of  the  right  lung  was  re- 
moved, by  transversely  cutting  out  a  wedge-shape  portion  of 
tissue.  The  edges  of  the  visceral  pleura  were  coaptated.  Au- 
topsy showed  the  operation  to  have  been  a  success.  In  another 
experiment,  a  perforation  was  made,  and  the  perforated  area 
was  sutured,  and  the  lung  replaced ;  the  dog  recovered.  Again, 
a  lobe  was  punctured  through  its  centre  with  a  knife;  perfect 
recovery  resulted.  In  still  another  case,  one-third  of  the  in- 
ferior lobe  of  the  right  lung  was  cut  away  transversely.  The 
dog  recovered  in  a  remarkably  short  time.  Several  experi- 
ments were  made  by  puncturing  the  lung,  and,  also,  by  remov- 
ing parts,  or,  the  whole  of  a  lobe.  In  all  cases  the  operations 
were  successful.     Once  two  ribs  were  resected,  in  order  to 


Plate  LXXIX. 


Pneumonopexy. 
Experiment  on  Lnngs,  No.  25,  page  491. 


THE   LUNG   OF   THE   DOG  473 

reach  the  upper  lobe  of  the  right  king.  This,  too,  proved  suc- 
cessful. 

It  has  been  found  during  these  experiments,  that  all  cases 
of  simple  incision  of  lung,  when  returned  to  the  cavity  without 
suturing,  have  recovered. 

Unless  a  lacerated  lung  has  been  sutured  previously  to  being 
returned  to  the  thoracic  cavity,  the  cut  surfaces  have  become 
adherent  to  the  parietal  pleura,  at  the  point  of  normal  apposi- 
tion. But  when  it  has  been  sutured  before  being  returned,  the 
lung  has  healed  without  pleuritic  adhesions. 

It  was  also  found,  that  after  a  lung  had  receded  upon  open- 
ing the  chest,  the  probabilities  are,  that  it  will  never  regain  its 
original  distention,  if  a  permanent  opening  be  left  in  the  chest 
wall,  and  adhesions  are  not  formed. 

The  removal  of  the  superior  border  of  any  lobe  was  more 
easily  accomplished  than  the  removal  of  the  inferior  border  of 
any  lobe. 

In  no  case  were  clots  found  in  the  post  mortems. 

Air  will  re-enter  compressed  lung  tissue  if  the  pressure  be 
not  too  great,  or  sustained  too  long.  In  each  case,  where  a 
portion  of  a  lung  was  excised,  the  remaining  portion  of  the  lung 
became  distended  sufficiently  to  occupy  the  entire  pleural 
cavity. 

Acceleration  of  respiration  and  circulation,  immediately 
after  operation,  was  remarked  in  all  cases,  the  degree  varying 
with  amount  of  lung  tissue  excised,  and  the  consequent  loss  of 
lung  capacity.  This  was  true  whether  it  was  a  case  of  re- 
moval, or  simple  occlusion  by  ligation,  or  otherwise. 

The  stomach  was  not  distended  with  gas  in  all  cases  of  in- 
fection. 

Large  dogs  withstood  the  operation  better  than  smaller  and 
younger  dogs. 

The  lungs  were  the  only  organs  examined  microscopically 
after  autopsy. 


PIL\CTICAL  HINTS  AND  THEORETICAL  CONSID- 
ERATIONS, DEDUCED  AND  SUGGESTED  BY 
THESE  EXPERIMENTS 

This  series  of  experiments  corroborates  the  conclusions  to 
be  drawn  from  the  reports  of  cases,  and  operations  for  lesions 
of  the  lungs. 

The  surgeon  should  never  hesitate  to  operate,  if  other  meas- 
ures fail.  There  should  be  no  hesitation,  even  though  the  case 
seems  particularly  desperate.  There  is  much  greater  prospect 
of  success  in  operating  for  all  forms  of  pulmonary  disease  than 
some  writers  would  have  us  think. 

Tait  claimed  that  deductions  from  experimental  operations 
on  dogs,  or  other  deep  and  narrow-chested  animals,  were  mis- 
leading. These  experiments,  however,  prove  that  surgical  in- 
terference in  pulmonary  troubles  is  far  from  being  impractical, 
or  unjustifiable.  The  reason  offered  for  decrying  the  applica- 
tion of  the  results  of  experiments,  is  based  on  the  fact  that 
only  healthy  animals  or  organs  are  operated  upon. 

The  experiments  which  form  the  basis  of  these  remarks 
were  made  on  such  dogs  as  could  be  obtained.  No  effort  was 
made  to  secure  healthy  dogs.  Even  when  several  dogs  were 
obtained  at  the  same  time,  the  dog  first  at  hand  was  used  with- 
out making  any  selection.  On  account  of  several  reasons 
(which  are  not  germane  to  the  subject)  no  special  care  was 
exercised  in  the  performance  of  the  operations ;  neither  did  the 
dogs  receive  any  particular  care  after  the  operations.  Anti- 
septic precautions  were  generally  neglected,  too.  Hence  the 
results  obtained  under  such  circumstances  are  all  the  more  re- 

474 


Plate  LXXX. 


Experiment  on  Lungs,  No.  26,  page  491. 


/ 


PRACTICAL  HINTS  AND  THEORETICAL  CONSIDERATIONS     4/5 

markable.  It  is  fair,  therefore,  to  assume  that  if  the  same 
operations  had  been  performed  on  human  subjects,  the  results 
would  have  been  as  good,  if  not  better.  For  in  making  such 
operations  on  human  patients,  greater  care  would  have  been 
exercised,  and  greater  precautions  observed  to  secure  asepsis. 

These  experiments  showed  that  stab  wounds  bleed  more 
than  bullet,  or  similar  wounds,  unless  important  vessels  be  in- 
jured. 

The  best  mode  of  operating  in  these  cases  is  to  excise  por- 
tions of  the  injured  lung,  and  suture  the  cut  edges,  and  it  is 
better  to  excise  portions  of  the  apices  of  a  perforated  lung, 
when  the  wound  is  at  the  border,  and  suture  the  edges,  than  to 
attempt  to  close  it  with  puckering  sutures.  In  some  cases,  it 
m.ay  be  best  to  incorporate  a  portion  of  the  lung  into  the  chest 
wall,  and  relieve  it  later. 

A  portion  of  one,  or  both  pneumogastric  nerves  may  be  re- 
moved without  danger,  or  permanent  ill  effect.  The  intimate 
connection  of  the  vagus  with  other  cranial  or  cerebrospinal 
nerves,  and  with  the  sympathetic,  accounts  for  the  danger  from 
injuries  to  this  nerve.  It  is  impossible  to  separate  the  fibres 
of  the  one  from  the  other. 

In  case  of  an  external  laceration  of  a  lobe,  and  if  the  con- 
trol of  haemorrhage  be  impossible,  or  doubtful,  it  is  safer  to 
extirpate  the  lobe.  This  is  the  proper  procedure  in  cases  of 
certain  forms  of  abscess,  active  destructive  gangrene,  or  de- 
struction of  a  greater  portion  by  necrosis. 

The  character  of  a  wound  in  the  lungs  is  influenced  by  sev- 
eral factors,  i.e.,  size  of  foreign  body;  velocity  of  missile; 
proximity  to  source  of  injury;  character  of  chest  wound, 
whether  fracture  or  not;  direction  of  missile;  whether  wound 
be  received  during  inspiration  or  expiration ;  environment ;  and 
extent  of  injury  to  the  vessels. 

In  pulmonary  operations,  the  incision  should  be  made  nearer 
the  spine  than  to  the  sternum,  as  it  will  be  easier  to  palpate,  and 
deliver  the  lung.     Perforating  instruments  should  not  be  used 


476  THE   SURGERY   OF   THE   LUNGS 

on  lung  tissue  that  is  to  be  left  in  the  chest  cavity.  It  is  bet- 
ter, too,  to  lacerate  the  lung,  than  to  cut  it,  as  there  will  be  less 
bleeding.  The  less  the  amount  of  lung  tissue  incorporated  in 
a  ligature  the  better. 

In  cases  requiring  the  ligation  of  the  bronchus :  first,  ligate 
the  bronchus ;  second,  ligate  the  vessels,  and  dissect  away  the 
lung  tissue.  This  must  be  done  sooner  or  later.  In  ligating 
the  bronchus,  the  ligature  should  be  applied  only  after  denuding 
the  rings  of  mucous  membrane.  The  bronchus  may  be  closed 
by  inverting  its  ends  and  suturing. 

Always  cut  or  ligate  transversely  to  the  bronchial  vessels ; 
parallel  sections  may  be  removed  this  way. 

When  an  entire  lobe  of  a  lung  is  removed,  several  ligatures 
should  be  used.  The  remaining  portion  of  the  lung  should  not 
be  ligated  "en  masse,"  but  only  small  portions  of  lung  tissue 
should  be  incorporated  in  any  one  ligature.  It  is  better  to  have 
too  many  than  too  few  ligatures.  The  operator  must  be  careful 
to  make  sure  that  the  ligatures  are  drawn  sufficiently  tight,  to 
preclude  all  danger  of  their  dislodgement. 

Drainage  is  to  be  used  in  gunshot,  incised  and  lacerated 
wounds.  It  is  to  be  used  in  all  cases  of  operation  for  abscess, 
gangrene  and  parasites.  Counter  drainage  is  only  to  be  em- 
ployed when  adhesion  to  the  parietal  pleura  has  not  taken  place. 
Drainage  is  just  as  important  in  operations  on  the  thoracic  or- 
gans, as  in  operations  on  the  abdominal  organs. 

In  case  of  a  punctured  wound,  do  not  be  afraid  of  placing 
the  sutures  too  deeply. 

In  case  a  lobe  has  been  removed,  and,  if  for  any  reason,  it  is 
thought  best  to  fix  the  stump  in  the  intercostal  space,  the  cu- 
taneous structures  should  be  sutured  over  it,  first  having  se- 
cured the  blood-vessels  and  bronchi.  Care  must  be  observed  to 
occlude  the  bronchia,  that  there  may  be  no  emphysema.  These 
experiments  proved  that  it  is  not  always  necessary  to  suture 
the  lung  tissue  itself;  ligating  the  blood-vessels  and  bronchia 
is  sufficient.     In  such  cases  the  lung  will  usually  become  adhe- 


PRACTICAL  HINTS  AND  THEORETICAL  CONSIDERATIONS     477 

rent  to  the  chest  wall.  In  case  blood  should  escape  into  the 
pleural  cavity,  no  danger  need  be  apprehended  in  traumatic 
injuries  of  the  lung,  if  the  removal  of  the  damaged  portion  of 
the  lung  has  been  properly  accomplished. 

Trauma,  from  forceps  in  grasping  the  lung,  will  produce 
sub-pleural  cedema.  This  appears  soon  after  the  operation, 
when  a  portion  of  the  lung  has  been  extirpated.  Hence  flat 
forceps,  with  rubber  coverings,  should  be  used  to  grasp  lung 
tissue,  and  the  forceps  should  not  be  removed,  until  this  portion 
of  the  lung  is  removed,  or  the  operation  completed. 

If  a  lobe  be  badly  lacerated,  by  a  piece  of  shell  or  otherwise, 
it  is  infinitely  safer  to  remove  the  lobe,  after  having  transfixed 
it  to  its  base,  or  to  the  undisturbed  tissue,  than  to  do  anything 
else. 

It  is  also  better  to  allow  an  injured  lobe  or  lung  to  remain 
contracted  with  an  open  chest  wall,  than  to  close  the  chest  with 
gauze  packing.  In  the  latter  case  the  lung  will  become  dis- 
tended, and  thereby  ceases  to  be  at  rest,  a  condition  most  favor- 
able for  the  repair  of  any  tissue.  This  is  especially  true  of  the 
lung,  because  the  lung  alternately  expands  and  contracts  upon 
itself  from  twenty  to  fifty,  and  even  more,  times  per  minute 
in  severe  injuries.  If  the  lung  can  be  kept  quiescent  w^ith  an 
open  chest  for  twenty  hours,  it  is  very  probable  that  it  will  be- 
come safely  distended  with  air  when  the  chest  wall  is  closed. 

In  cases  of  wounds  of  the  chest  wall  involving  the  lung, 
this  retraction  of  the  lung  always  occurs.  The  retraction  of  the 
lung  favors  the  stoppage  of  haemorrhage,  because  it  causes  a 
forcible  contraction  of  the  blood-vessels ;  a  clot  is  formed,  which 
stops  the  bleeding.  But  when  the  external  wound  becomes 
closed,  by  the  formation  of  a  clot,  or  otherwise,  the  lung  will 
suddenly  expand.  The  force  exerted  by  the  expansion  of  the 
lung,  under  these  circumstances,  is  greater  than  in  normal  ex- 
pansion. The  pressure  thus  suddenly  exerted  forces  the  clot 
out,  and  the  haemorrhage  will  be  renewed.  This  will  occur 
again  and  again,  until  the  wound  finally  heals.     If  immobility 


478  THE  SURGERY  OF  THE  LUNGS 

can  be  maintained  for  a  few  days,  or  a  week,  there  will  be  no 
question  of  recovery. 

There  is,  apparently,  no  limit  to  the  degree  to  which  the 
lung  may  be  compressed.  There  have  been  no  accurate  obser- 
vations made  on  this  point.  It  can  hardly  be  determined  ex- 
perimentally, because  animals  cannot  be  kept  sufficiently  quiet 
except  by  the  use  of  anaesthetics,  or  by  force.  In  either  case 
the  validity  of  the  results  obtained  would  be  questionable. 
Anaesthetics,  if  they  did  not  cause  death,  would,  very  likely, 
cause  complications  that  would  vitiate  results.  The  use  of 
force  would  defeat  the  very  object  which  it  was  intended  to 
secure.  Hereafter,  no  doubt,  greater  care  and  accuracy  will  be 
employed  in  making  observations  on  this  point  in  man. 

In  case  the  apex  of  a  lung  is  lacerated,  or  incised,  while 
distended,  and  the  laceration,  or  incision,  is  not  over  three 
inches  in  length,  it  is  safer  to  allow  it  to  be  undisturbed,  espe- 
cially if  there  is  no  bleeding.  It  may  become  adherent  to  the 
parietal  pleura,  but  this  is  better  than  to  cause  additional  in- 
jury by  an  attempt  to  suture. 

The  treatment  of  an  injured  bronchus  depends  upon  the 
character  of  the  wound;  whether  the  laceration,  or  incision,  be 
transverse,  or  longitudinal  to  the  bronchus.  If  the  bronchus 
has  been  opened  for  the  purpose  of  making  an  exploration,  it  is 
the  practice  of  some  to  pack  instead  of  suturing.  But  this  pro- 
cedure is  not  advisable  if  it  is  necessary  to  divide  the  bronchus 
transversely,  because  of  the  possibility,  and  probability,  of  end 
to  end  anastomosis  not  occurring.  In  all  cases  where  the 
bronchus  is  severed  transversely,  and  in  cases  of  longitudinal 
wounds  produced  by  injury,  it  would  be  better  to  suture,  apply- 
ing the  same  methods  as  are  used  in  similar  wounds  of  the  in- 
testines. It  is  a  question  whether  it  would  not  be  safer  to 
suture  all  wounds  of  the  bronchus. 

A  stout,  healthy,  normal  dog  can  withstand  the  removal 
of  either  the  right  or  left  lung,  entire.  This  has  been  done  with 
the  left  lung  in  one  of  these  experiments. 


Plate  LXXXI. 


Experiment  on  Lungs,  No.  27,  page  492. 


PRACTICAL  HINTS  AND  THEORETICAL  CONSIDERATIONS     479 

The  removal  of  one  or  more  lobes  of  a  healthy,  normal  lung 
is  likely  to  produce  more  serious  results  than  the  removal  of  one 
or  more  lobes  of  a  diseased  lung ;  for,  during  the  progress  of  the 
disease,  there  has  been  a  gradual  loss  of  lung  capacity,  propor- 
tional to  the  extension  of  the  disease;  while  the  loss  of  lung  ca- 
pacity following  the  excision  of  one  or  more  lobes  of  a  healthy 
lung  is  sudden.  In  cases  of  this  kind,  the  remaining  portion  of 
the  lung  will  expand,  and  together  with  the  diaphragm  fill  the 
space  originally  occupied  by  the  whole  lung.  Of  course,  a  part 
of  a  lung  cannot  perform  the  functions  of  a  whole  lung.  Just 
how  large  a  portion  of  a  lung  must  be  left,  in  order  that  the  cav- 
ity may  be  filled  by  the  expansion  of  this  remnant  together  with 
the  upward  movement  of  the  diaphragm,  is  not  exactly  known. 
The  alveoli  may  be  expanded  to  almost  any  degree,  but  from 
experiments,  it  has  been  determined  that  the  alveoli  lose  their 
elasticity  when  excessively  dilated.  The  loss  of  elasticity 
causes  a  cessation  of  function.  The  exact  amount  of  lung  tis- 
sue that  may  be  lost,  without  causing  loss  of  function  in  the 
remaining  portion  of  the  lung,  has  not  been  accurately  deter- 
mined. It  is  a  question,  too,  whether  this  expansion  for  the 
purpose  of  helping  to  fill  the  space  occupied  by  the  whole  lung, 
in  compensation  for  the  lost  portion,  does  not  cause  a  diminu- 
tion of  function.  It  is  extremely  probable  that  there  is  a  de- 
crease of  function  in  the  mutilated  lung  greatly  out  of  propor- 
tion to  the  amount  of  lung  tissue  lost. 

It  is  probable  that  if  a  lung  were  excised  lobe  by  lobe,  in  suc- 
cessive operations,  that  the  mortality  would  be  much  less  than 
if  the  entire  lung  were  removed  in  one  operation.  If  sufficient 
time  is  permitted  to  elapse  between  each  operation,  for  recovery 
from  the  preceding,  it  is  probable  that  the  shock  would  be  less 
with  each  successive  operation. 

It  is  very  probable  that  the  percentage  of  recoveries,  from 
the  excision  of  one  or  more  lobes  of  a  diseased  lung,  would  be 
greater  than  the  percentage  of  recoveries  from  the  excision  of 
one  or  more  lobes  of  a  healthy  lung. 


480  THE  SURGERY  OF  THE  LUNGS 

In  case  of  a  wound  of  the  lung,  or  when  there  are  grounds 
for  supposing  the  lung  to  be  injured,  the  patient  should  not  be 
disturbed  in  order  to  make  a  positive  diagnosis.  Immobility, 
and  quietude  are  absolutely  essential  in  all  wounds  of  the  lungs. 

No  man  is  infallible — even  with  all  the  aids  provided  by 
modern  science,  it  is  not  always  possible  to  make  a  positive  di- 
agnosis. At  times,  diagnostic  signs,  which  almost  always  in- 
dicate certain  conditions,  are  misleading.  Some  of  the  most 
prominent  and  experienced  surgeons  have  had  such  experiences. 

The  success  or  failure  of  pulmonary  operations  centre  about 
the  kind  of  sutures,  and  the  kind  of  material  employed. 

There  has  always  been  controversy  over  the  kind  of  mate- 
rial that  should  be  used  for  ligating  and  suturing.  Absorbable 
and  nonabsorbable  suture  materials  have  their  advocates.  It  is 
true  that  there  are  operations,  the  success  of  which  will  be  more 
assured  by  the  use  of  absorbable  suture  material ;  there  are  other 
circumstances  when  it  would  be  better  to  use  non-absorbable 
material.  It  is  only  by  experience,  combined  with  a  thorough 
knowledge  of  the  anatomy,  physiology,  etc.,  of  the  tissues  in- 
volved in  the  operation,  that  one  is  enabled  to  make  the  proper 
selection  of  material,  and  kind  of  suture  to  employ. 

Many  pulmonary  operations  have,  no  doubt,  been  failures 
because  wrong  selections  have  been  made  of  the  kind  of  material 
used  in  suturing,  or  the  wrong  kind  of  suture  used,  or  both. 
Failures  have  been  caused  also,  by  sutures  being  placed  too  near 
the  lips  of  the  wound,  or  by  the  punctures  of  the  needle  being 
too  close  together. 

It  is  better  to  have  too  few  sutures  than  too  many,  but  with 
regard  to  ligatures  it  is  better  to  have  too  many  than  too  few. 

When  an  antiseptic  ligature  is  placed  in  aseptic  tissues,  there 
is  no  destructive  change  to  weaken  the  vessel  walls,  therefore 
the  ligature  should  include  a  minimum  amount  of  vascular  tis- 
sue, and  should  never  be  applied  in  such  a  way  as  to  lacerate  the 
walls  of  an  artery. 

The  best  needle  for  lung  surgery  is  a  coarse,  blunt  one,  just 


PRACTICAL  HINTS  AND  THEORETICAL  CONSIDERATIONS     48  I 

large  enough  to  take  whatever  material  is  selected  for  suturing. 
By  the  use  of  a  blunt  needle,  the  danger  of  wounding  the  deli- 
cate vessels  and  bronchia  which  ramify  through  the  lung,  is 
reduced  to  a  minimum. 

The  puncture  of  a  needle  should  not  be  closer  than  one-half 
inch  to  the  margins  of  the  wound. 

All  stumps  of  lung  tissue  should  be  secured  by  transfixion ; 
that  is,  the  needle  armed  with  kangaroo  tendon  should  be  passed 
through  the  thickness  of  the  lung,  and  tied.  It  is  a  combina- 
tion of  ligature  and  suture. 

At  times  it  is  not  advisable  to  suture,  and  in  such  cases,  a 
clamp  or  clamps  should  be  applied.  The  clamp  may  be  al- 
lowed, if  necessary,  to  protrude  through  the  opening  in  the 
chest  wall. 

Under  no  circumstances  should  torsion  or  acupressure  be 
employed  to  secure  blood-vessels  in  the  lungs.  In  all  cases  of 
chest  wounds  involving  the  lung,  the  lung  will  retract.  It  will 
also  retract  on  an  attempt  to  suture  it,  if  it  is  not  already  re- 
tracted ;  but  as  soon  as  the  external  chest  wound  is  closed,  the 
lung  will  immediately  expand  with  greatly  increased  force. 
Torsioned  vessels  will  give  way  to  a  force  of  one-half  an  atmos- 
phere, in  addition  to  the  normal  blood  pressure ;  vessels,  secured 
by  acupressure,  will  not  withstand  a  force  of  one  atmosphere  in 
addition  to  the  normal  blood  pressure.  The  force  exerted  by 
the  sudden  expansion  of  the  lung,  under  the  above  circum- 
stances, will  amount  to  at  least  two  atmospheres.  Ligation  is 
the  only  method  of  securing  blood-vessels  that  will  sustain  this 
pressure. 

Do  not  place  sutures  near  the  edges  of  a  wound,  especially 
'if  it  is  an  incision.  If  there  is  haemorrhage,  ligate  the  bleeding- 
vessels  by  transfixion. 

The  "  concealed,"  or  *'  interrupted  "  sutures  should  never 
be  used  in  operations  on  the  lung. 

If  fine  suture  material  is  used,  or  if  sutures  are  placed  too 
close  together,  or  too  near  the  edges  of  the  wound,  the  sutures 


482  THE  SURGERY  OF  THE  LUNGS 

will  tear  out.  Fine  material,  even  if  placed  at  the  proper  dis- 
tance from  the  margins  of  the  wound,  will  cut  the  lung  tissue. 
For  all  purposes,  kangaroo  tendon  is  the  best  material  to  employ 
for  suturing  the  lung ;  because  of  its  relatively  large  size,  the  su- 
tures may  be  placed  farther  apart,  and  may  also  be  tied  more 
tightly  without  danger  of  cutting  the  lung  tissue,  and  the  swell- 
ing caused  by  absorption  of  serum  will  aid  in  preventing 
bleeding. 

This  series  of  experiments  demonstrates  certain  kinds  of 
sutures  to  be  more  suitable  than  others.  Among  those  that 
proved  of  special  value  were  the  "  whip-stitch,"  which  is  simply 
an  over  and  over  continued  suture;  the  "tug-stitch";  the 
"  continued  "  suture ;  the  "  mattress  "  or  "  quilted  "  suture;  the 
"  glover's  "  suture;  the  "  lace,"  and  "  Bell's." 

The  whip-stitch  is  to  be  used  in  simple  superficial  incision, 
or  lacerations.  The  ordinary  continuous  suture  is  also  useful 
for  the  same  purpose.  A  combination  of  the  mattress  and  con- 
tinuous sutures  is  useful  in  extensive  superficial  incisions,  and 
lacerations.  The  glover's  is  best  adapted  for  incisions  near  the 
base  of  the  lung,  as  it  will  keep  the  margins  of  the  wound  from 
everting.  The  Bell  suture  is  best  adapted  for  wounds  in  those 
parts  of  the  lung  where  there  is  the  least  strain  from  the  activ- 
ity of  the  lung.  The  herringbone  stitch  is  also  of  great  utility 
in  preventing  the  lips  of  a  wound  from  everting.  The  mat- 
tress, or  quilted  suture  is  best  adapted  for  deep  incisions,  or 
lacerations  which  do  not  extend  through  the  entire  thickness 
of  the  lung.  The  tug-stitch  is  the  only  suture  that  will  answer 
in  case  of  an  incision,  or  laceration  extending  through  the  entire 
thickness  of  a  lobe  at  its  base;  in  other  words,  when  a  lobe  is 
split.  This  suture  is  only  an  adaptation  of  the  saddlers'  stitch," 
which  he  employs  in  sewing  a  trace,  etc.  Two  needles  are  used ; 
one  is  passed  through  the  entire  thickness  of  the  lung,  at  a  dis- 
tance of  one-half  inch  from  the  lip  of  the  wound;  it  emerges 
posteriorly,  on  the  same  side  of  the  wound  as  it  entered.  The 
second  needle  is  passed  from  the  posterior  surface  of  the  lung, 


Plate    LXXXII 


Experiment  on  Lungs,  No.   28,  page  492. 


PRACTICAL  HINTS  AND  THEORETICAL  CONSIDERATIONS     483 

through  the  entire  thickness  of  the  king ;  it  emerges  anteriorly 
through  the  puncture  made  by  the  first  needle.  The  puncture 
of  the  second  needle  is  made  on  the  same  side  of  the  wound  as 
that  of  the  first  needle.  Then  the  second  needle  is  passed,  still 
on  the  same  side  of  the  wound,  from  the  anterior  surface  of  the 
lung,  through  the  entire  thickness  of  the  lung,  to  the  posterior 
surface,  and  there  emerges,  on  the  same  side  of  the  wound  as  it 
entered.  The  first  needle  is  then  passed  through  the  puncture, 
just  made  by  the  second  needle,  to  the  anterior  surface,  where  it 
emerges  from  the  opening  made  by  the  entrance  of  the  second 
needle.  This  procedure  is  continued  until  this  side  of  the 
wound  has  been  sutured  in  its  entire  length.  Then  the  other 
side  of  the  wound  is  sutured  in  the  same  manner. 

The  author  devised  a  suture  which  he  found  to  answer  bet- 
ter than  any  other  for  cases  where  the  wound  was  caused  by  a 
puncture,  or  perforation,  and  a  piece  of  lung  tissue  had  been 
torn  out. 

This  suture  is  a  combination  of  the  lace  and  tobacco-pouch, 
or  tug-stitch.  A  single  curved  needle  is  used.  The  needle  is 
dipped  rather  deeply  into  the  lung  tissue  about  one-half  inch 
from  the  edge  of  the  wound,  then  it  is  made  to  emerge  about 
one-half  inch  from  place  of  entrance ;  this  procedure  is  repeated 
until  the  entire  wound  is  encircled  with  sutures.  Then  a  sec- 
ond row  of  sutures  is  made ;  each  stitch  of  the  second  row  being- 
so  placed  as  to  alternate  with  the  first.  In  other  words,  where- 
ever  the  kangaroo  tendon,  of  the  first  row  of  sutures,  is  on  the 
surface  of  the  lung,  that  of  the  second  row  will  be  below  the 
surface.  By  this  means  the  wound  is  not  only  entirely  encircled 
by  sutures,  but  the  tissue,  surrounding  the  perforation,  is  com- 
pressed. This  compression  of  the  tissues  also  compresses  the 
vessels,  which  have  been  severed,  and  the  haemorrhage  is 
stopped. 


DESCRIPTION    OF    PLATES    I    AND    LVII 
TO    LXIII 

PLATE  I 

This  plate  gives  an  anterior  view  of  the  heart  and  lungs,  in  situ,  of  a  dog  weigh- 
ing about  forty-five  pounds.  The  arteries,  veins,  and  bronchia  were  injected  with 
starch.  This  procedure  completely  distended  the  organs,  and  caused  them  to 
assume,  and  retain  the  shape  of  the  thoracic  cavity.  The  most  striking  feature, 
perhaps,  which  reveals  itself  at  a  first  glance,  is  how  nature  provides  protection 
for  the  most  important  organs.  It  shows  that  the  right  upper  lobe  of  the  lung 
overlaps  the  entire  upper  portion  of  the  heart,  while  the  left  upper  lobe  affords 
like  protection  to  the  other  side;  the  middle  lobe  too  closes  in  around  the  heart, 
thus  forming  a  natural,  living  air  cushion,  to  ward  off  injuries,  and  sudden  shocks 
to  the  heart. 

The  right  upper  lobe  (i)  extends  across  the  upper  part  of  the  chest,  meeting 
the  left  upper  lobe.  At  (2)  is  the  right  middle  lobe  (the  cord  seen,  is  a  rubber  band 
used  to  hold  the  lungs  while  being  photographed).  Immediately  below  is  shown 
the  curled  edge  of  the  right  lower  lobe  (3);  this  lobe  is  much  larger  than  the  others. 
In  fact,  it  appears  as  if  the  right,  middle  lobe  (2)  was  but  a  process  of  the  right 
lower  lobe.  Just  below  the  right  middle  lobe,  is  seen  a  cord;  this  is  the  end  of  a 
ligature  around  the  aorta. 

The  heart  is  shown  in  its  nest-like  surroundings  at  (5).  The  left  upper  lobe 
(6)  overlaps  the  right  upper  lobe,  completing  the  air-cushion-like  protection  of 
the  heart.  The  left  middle  lobe  (7)  overlaps  the  upper  (6)  and  lower  (8)  lobes, 
thus  filling  the  space  between  the  two. 

The  white  spots  are  caused  by  the  escape  of  some  of  the  starch,  used  to  inject 
the  vessels. 

PLATE  LVII 

This  plate  gives  a  posterior  view  of  the  same  organs  shown  in  plate  la. 

The  arteries,  veins,  and  bronchia  are  distended  with  starch.  The  left  upper 
lobe  is  shown  at  (i).  The  thoracic  aorta  (2),  is  clearly  seen,  together  with  its 
intercostal  branches.  The  latter  are  placed  in  pairs,  opposite  one  another.  The 
left  lower  lobe  (3)  extends  more  toward  the  neck  but  not  as  low  down  as  does  the 
right  lower  lobe  (7).  The  bronchial  gland  (4)  is  well  brought  out  in  the  plate. 
Only  a  point  of  the  right  middle  lobe  (6)  can  be  seen  in  this  view.  The  right 
upper  lobe  (5)  extends  higher  toward  the  neck,  and  not  so  far  down  as  does  the 
corresponding  left  lobe. 

PLATE  LVIII 

A  TRANSVERSE   SECTION   OF   THE   LOWER   LOBES 

The  posterior  aspect  is  shown  at  (6).  The  white  spots  are  caused  by  the  exud- 
ing of  the  starch  with  which  the  vessels  were  injected. 

The  lower  wing  of  the  butter-fly  lobe  (i)  is  shown  resting  on  a  rubber  band. 

(2)  The  left  middle  lobe. 

(3)  Apex  of  the  heart. 

484 


DESCRIPTION   OF   PLATES  485 

(4)  The  right  middle  lobe. 

(5)  Upper  wing  of  butterfly  lobe.. 

As  has  been  remarked,  in  explanation  of  Plate  la,  the  lung  forms  an  air-cushion- 
like protection  to  the  heart  anteriorly,  while  it  is  partially  protected  in  the  same 
way  posteriorly,  in  addition  to  the  support,  and  protection  afforded  by  the  spined 
column  and  ribs. 

PLATE   LIX 

A,  TRANSVERSE    SECTION     OF    THE     LOWER    LOBES,    TOGETHER    WITH    THE    LOWER 
WING    OF  THE   BUTTERFLY  LOBE,   AND   APEX  OF  THE   HEART 

The  white  spots  in  this  plate,  as  in  all  the  others,  are  due  to  the  starch  escaping 
from  the  various  vessels. 

(i)  The  oesophagus;  just  above,  is  seen  one  of  the  mediastinal  vessels. 

(2)  A  transverse  section  through  apex  of  the  heart. 

(3)  Section  of  lower  wing  of  butterfly  lobe. 

(4)  The  upper  vdng  of  butterfly  lobe. 

PLATE  LX 

A  POSTERIOR  VIEW  OF  A  TRANSVERSE  SECTION  OF  THE  LOWER  LOBES 

(i)  A  section  of  the  bronchus. 

(2)  Section  of  a  bronchus  in  the  body  of  the  lung. 

(3)  Section   of   heart. 

(4)  A  venesection. 

(5)  The  bifurcation  of  bronchus  in  right  lower  lobe. 

(6)  End  of  middle  lobe. 

(7)  End  of  middle  of  butterfly  lobe. 

(8)  The  oesophagus. 


PLATE  LXI-A 

FOURTH   POSTERIOR   VIEW 

(1)  Section  of  left  middle  lobe. 

(2)  CEsophagus. 

(3)  Left  upper  lobe. 

(4)  Section  of  left  bronchus. 

(5)  Section  of  the  right  upper  lobe. 

(6)  Part  of  right  upper  lobe. 

PLATE   LXI-B 

FIFTH   POSTERIOR   VIEW 

(i)  Arch  of  the  aorta,  distended  with  starch. 

(2)  The  great  pulmonary  vein. 

(3)  Portion  of  the  left  upper  lobe. 

(4)  The  thoracic  aorta. 

(5)  Portion  of  heart. 

(6)  The  oesophagus. 

(7)  The  trachea,  from  which  the  starch  is  exuding. 

(8)  Under  side  of  the  right  upper  lobe. 


486  THE   SURGERY   OF   THE   LUNGS 


PLATE   LXII-A 

SIXTH   POSTERIOR   VIEW 


(i)  Section  of  the  left  upper  lobe. 

(2)  The   left   bronchus. 

(3)  The  oesophagus. 

(4)  The  trachea,  partially  injected, 
(s)  Section  of  the  right  upper  lobe. 


PLATE   LXH-B 

(i)  The  posterior  aspect  of  the  main  bronchus. 

(2)  The  oesophagus. 

(3)  Trachea,  partially  injected. 

(4)  Section  of  the  right  upper  lobe. 

(5)  A  section  of  the  left  upper  lobe. 


PLATE  LXIII 

A  POSTERIOR  VIEW  OF  A  TRANSVERSE  SECTION  OF  THE  LOWER  LOBES,  FROM  A  STILL 

DIFFERENT    ASPECT 

(i)  Extreme  end  of  the  left  upper  lobe. 

(2)  The  oesophagus. 

(3)  Section  of  the  trachea. 

(4)  Extreme  end  of  the  right  upper  lobe. 


Plate  LXXXill. 


Experiment  on  Lungs,  No.  30,  page  492. 


RECORD    OF    EXPERIMENTS 

1.  June  30,  1900. — Black  curbstone  setter;  weight,  20  pounds; 
age,  8  months.     Right  side  of  chest.     Death  occurred  while  operating. 

Autopsy  made  one  hour  later.  No  special  cause  of  death  discov- 
ered, probably  due  to  anaesthetic.  Specimen  was  not  photographed, 
because  of  no  special  interest. 

2.  July  8,  1900. — Water  spaniel  bitch,  one  year  old;  weight,  22 
pounds.  At  II  A.M.,  one-third  of  inferior  lobe  of  right  lung  removed 
through  the  fifth  intercostal  space  after  resection  of  fifth  rib,  and  stump 
of  lung  anchored  to  chest  wall.  All  tissues  sutured  with  silk-worm 
gut,  and  stump  covered  with  skin.  Dog  died  at  10:30  a.m.,  July  12, 
1900. 

Autopsy. — Pleural  cavity  was  filled  with  pus;  all  organs  appeared 
normal.  Death  due  to  exhaustion,  from  infection.  Stump  of  lung, 
soft,  and  adherent  to  the  chest  wall.  Infection  probably  due  to  want 
of  caution,  while  chest  cavity  was  open. 

3.  July  10,  1900. — Bitch,  3  months  old;  weight,  10  pounds.  In- 
ferior lobe  of  right  lung  removed,  after  ligating  the  bronchus,  and 
vessels  at  base,  with  silk  without  transfixion  (purposely).  Thirty 
minutes  after  operation  respiration  registered  80  per  minute;  pulse, 
very  rapid.     Death  occurred  July  19,  1900. 

Autopsy  showed  perfect  repair  in  stump ;  exhaustion,  from  infection, 
was  the  probable  cause  of  death. 

4.  July  19,  1900. — Cur  dog,  one  and  a  half  year  old;  weight,  20 
pounds.  Inferior  lobe  of  right  lung  removed,  and  stump  ligated  with 
silk  by  transfixion,  and  chest  closed  by  silk-worm  gut.  Death  occurred 
at  7:30  A.M.,  July  2 1  St. 

Autopsy. — Liver  much  enlarged;  gall  bladder  greatly  distended 
with  bile;  stomach  was  also  distended  with  gas.  The  ligature  around 
stump  had  cut  through  a  mass  of  lung  tissue,  which  had  by  accident 
been  included  within  it.  Pleural  cavity  on  right  side  contained  six 
ounces  of  bloody  fluid,  indicating  that  death  was  probably  due  to  a 
slow  haemorrhage,  from  an  imperfectly  ligated  stump.  There  were 
no  adhesions  of  the  parietal  with  the  visceral  pleura.  The  ends  of  the 
silk-worm  gut  are  to  be  seen  in  the  photograph.     (Plate  LXIV.) 

5.  July  20,  1900. — Common  cur  bitch,  seven  months  old;  weight 
30  pounds.     A  silk  ligature  was  appHed  to  one-half  of  middle  lobe  of 

487 


488  THE  SURGERY  OF  THE  LUNGS 

right  lung,  after  having  deUvered  it  through  the  chest  wall  with  forceps. 
The  transfixed,  and  ligated  portion  of  the  lung  was  cut  away  with  scis- 
sors. There  was  no  haemorrhage  from  the  stump,  which  was  returned 
to  the  pleural  cavity.     Death,  July  22,  1900. 

Autopsy. — The  ligature  had  cut  through  stump,  allowing  about 
five  ounces  of  blood  to  escape  into  the  pleural  cavity.  Death  was  due 
to  exhaustion  from  haemorrhage.  No  doubt,  the  amount  of  blood 
contained  within  the  pleural  cavity  had  been  lessened  by  constant 
absorption. 

6.  July  20,  1900. — Common  dog,  six  years  old;  weight,  30  pounds. 
A  kangaroo  tendon  was  passed  through  one-half  of  lower  lobe  of  left 
lung,  close  to  bronchus,  allowing  the  incorporated  mass  to  remain. 
Closed  wall  with  silk-worm  gut.  Dog  died  during  the  night  of  July 
23,  1900. 

Autopsy  showed  ligature  to  have  escaped  by  sloughing  of  stump; 
there  was  also  general  pleurisy  and  about  half  a  pint  of  flocculent  pus. 

A  white  pleuritic  membrane  extended  over  the  entire  visceral  and 
parietal  pleura,  upon  the  left  side.     (Plate  LXV.) 

7.  July  20,  1900. — Bulldog,  one  year  old;  weight,  40  pounds.  The 
same  procedure  as  in  No.  6,  except  that  the  middle  of  the  upper  lobe 
of  the  right  lung  was  ligated,  by  throwing  a  kangaroo  tendon  around 
the  middle  of  the  lobe,  including  the  bronchus,  the  lumen  of  which  was 
occluded.  None  of  the  strangulated  portion  of  the  lung  was  removed. 
The  chest  wall  was  closed  in  the  usual  way.  The  dog  was  killed  on  the 
ninth  day  following  the  operation.     (Plate  LXVI.) 

Autopsy  demonstrated  the  perfect  repair  of  the  lung.  There  were 
pleuritic  adhesions,  here  and  there,  in  both  the  right  and  left  sides, 
those  upon  the  right  having  occurred  subsequent  to  the  operation. 
The  age  of  those  upon  the  left  side  was  doubtful.  The  photograph 
shows  the  perfect  union.     The  large  white  spot  is  the  cicatrix. 

8.  July  21,  1900. — Black  mongrel  dog,  one  year  old;  weight,  20 
pounds.  The  inferior  lobe  of  the  right  lung  was  divided  by  the  knife, 
for  two-thirds  of  its  length;  no  special  bleeding.  The  edges  of  the 
wound  were  coaptated,  using  the  glover's  suture  through  and  through, 
and  lobe  returned  to  the  pleural  cavity.  The  dog  was  killed  nine  days 
after  the  operation. 

Autopsy  revealed  perfect  repair,  with  adhesions  of  the  visceral  to 
the  parietal  pleura.  The  denuded  lung  was  found  adherent  to  the 
chest  wall,  at  its  proximity,  during  normal  expansion.  The  illustration 
shows  the  point  of  perfect  repair.     (Plate  LXVII.) 

9.  July  21,  1900. — Brown  cur,  one  year  old;  weight,  14  pounds. 
The  butterfly  lobe  of  right  lung  was  removed;  silk-worm  gut  was  used 
for  ligature,  and  also  to  close  the  chest.  The  lower  lobe  was  consider- 
ably lacerated  with  forceps,  in  an  endeavor  to  deliver  it  for  attack. 
Dog  died  4  p.m.,  July  24,  1900. 


Plate  LXXXIV. 


ExpERiAiEMT  ON  LuNGS,  No.  31.    page  492. 


RECORD   OF   EXPERIMENTS  489 

Autopsy. — Right  pleural  cavity  contained  four  ounces  of  purulent 
pleuritic  effusion.  No  pleuritic  adhesions  present.  Death  probably 
due  to  infection. 

10.  July  21,  1900. — Brown  water-spaniel,  one  year  old;  weight, 
20  pounds.  A  portion  of  the  fifth  and  sixth  ribs  upon  the  right  side 
was  removed  with  forceps.  The  lung  was  then  exposed,  and  forceps 
thrust  through  the  entire  thickness  of  the  lung,  near  the  base  of  the 
inferior  lobe.  A  piece,  about  the  size  of  a  silver  quarter,  was  torn 
from  the  centre  of  the  lobe.  The  opening  was  closed  by  the  pucker- 
ing, or  lace  suture,  using  silk-worm  gut.  The  entire  circle  was  trav- 
ersed, by  passing  the  needle  back  and  forward.  The  lobe  was 
returned  to  the  pleural  cavity,  and  opening  in  chest  wall  closed  with 
silk-worm  gut.     (Plate  LXVIII.) 

•  II,  July  22,  1900. — Black  spaniel,  eight  months  old;  weight,  18 
pounds.  The  lung  was  exposed,  and  an  incision,  one  and  a  half  inches 
long,  made  in  the  superior  lobe  of  right  lung.  The  lung  was  then 
returned  to  the  pleural  cavity,  without  suturing,  or  any  other  attention, 
and  the  chest  wall  closed. 

Autopsy,  seven  days  after  operation,  showed  perfect  repair,  with 
adhesions  of  visceral  and  parietal  pleura.  The  edges  of  the  wound 
united  nicely.     There  was  only  a  Hne-hke  cicatrix.     (Plate  LXIX.) 

12.  July  22,  1900,  7  A.M. — Common  cur,  eight  months  old;  weight, 
22  pounds.  The  inferior  lobe  of  the  right  lung  was  removed.  Silk- 
worm gut  was  used  to  ligate  the  stump,  which  was  transfixed.  The 
dog  died  thirty-six  hours  after  the  operation. 

Autopsy. — There  were  found  one  and  a  half  pints  of  bloody  serum 
in  the  right  pleural  cavity.  Stump  was  found  to  be  in  good  shape, 
except  a  small  portion  of  the  lung,  which  was  not  incorporated  in  the 
ligature.  Death,  probably  due  to  haemorrhage,  from  non-incorporated 
portion  of  the  lung. 

13.  July  24,  1900. — Mixed  bull,  one  and  a  half  year  old;  weight, 
35  pounds.  At  6:30  A.M.,  removed  one-half  of  the  inferior  lobe  of  the 
right  lung,  using  kangaroo  tendon  for  tug  stitching.  The  chest  wall 
was  closed  with  silk-worm  gut.     August  9th  the  dog  was  killed. 

Autopsy  revealed  complete  recovery  and  perfect  repair.  (Plate 
LXX.) 

14.  July  24,  1900. — Fox-terrier  bitch,  one  and  a  half  year  old; 
weight,  15  pounds.  Removed  inferior  lobe  of  right  lung,  by  tying 
stump  in  three  sections.  The  vessels  were  first  ligated  at  the  base, 
with  silk-worm  gut  on  either  side  of  bronchus.  The  bronchus  was 
then  occluded  by  silk-worm  gut.     Killed  dog  August  9th. 

Autopsy  showed  that  repair  was  far  enough  advanced  to  assure  the 
preservation  of  life.  The  illustration  shows  stump,  and  silk-worm  gut 
ligature,  firmly  fixed  in  the  lung  tissue.     (Plate  LXXI.) 

15.  July  24,  1900. — Fox-terrier  bitch,  age  ten  months;  weight, 
12  pounds.     Cut  off  portion  of  inferior  lobe  of  right  lung  with  knife; 


490  THE  SURGERY  OF  THE  LUNGS 

silk-worm  gut  was  used  for  Bell  sutures.  Stump  was  fixed  in  the  inter- 
costal space;  edges  of  the  integument  were  sutured,  to  allow  the  lung 
stump  to  be  exposed.     Dog  died  on  the  seventh  day. 

Autopsy  showed  pneumonia  of  middle,  and  butterfly  lobe  of  right 
lung. 

i6.  July  26,  1900. — Tall  dog,  two  years  old;  weight,  50  pounds. 
Removed  inferior  lobe  of  right  lung;  using  kangaroo  tendon  and  silk- 
worm gut  to  whip-stitch  stump.  Dog  killed  on  fourteenth  day  after 
operation. 

Autopsy  revealed  perfect  repair  of  stump,  and  complete  recovery. 
A  portion  of  silk-worm  gut,  and  a  small  piece  of  kangaroo  tendon 
were  seen — the  latter  was  in  process  of  disintegration.  The  photo- 
graph shows  all  these  features.     (Plate  LXXII.) 

17.  July  25,  iQoo.^Black  mixed  spaniel;  age,  one  year;  weight, 
25  pounds.  Removed  entire  inferior  lobe  of  right  lung,  using  trans- 
fixed, braided  silk  for  tug  suture.     Death  six  days  later. 

Autopsy  showed  open  stump.  The  ligature  had  been  drawn  tight 
enough  about  the  lung  tissue,  which  was  degenerated.  Although  the 
ligature  was  loose,  the  bronchus  had  become  occluded.  No  satis- 
factory explanation  for  cause  of  death  could  be  formed  from  appear- 
ance of  the  organs,  since  they  all  seemed  normal. 

18.  July  25,  1900. — Gray  shepherd  dog,  one  year  old;  weight,  25 
pounds.  Removed  the  lower  two-thirds  of  inferior  lobe  of  the  right 
lung  by  cutting,  transversely,  a  wedge-shaped  portion  of  lung  tissue. 
This  was  done,  to  allow  the  edges  of  the  visceral  pleura  to  be  coaptated, 
first  with  catgut,  and  then  with  kangaroo  tendon.  The  right  pleural 
cavity  was  packed  with  gauze,  one  end  of  which  was  allowed  to  protrude 
out  of  the  chest  wall.     Dog  died  five  days  later.     (Plate  LXXIII.) 

Autopsy  did  not  reveal  the  cause  of  death.  It  was  probably  due 
to  infection.  The  gauze  was  slightly  discolored  with  serum;  no  pleu- 
ritic adhesions;  no  pus  in  pleural  cavity.  Repair  of  stump  had  been 
progressive,  as  shown  by  the  complete  absorption  of  the  catgut,  and 
union  of  coaptated  edges  of  the  divided  lung  tissue.  This  case  well 
illustrates  the  comparative  life  of  cat-gut,  and  kangaroo  tendon. 

19.  July  25,  1900. — White  terrier  bitch,  one  year  old;  weight,  15 
pounds.  Chest  wall  opened,  and  a  pair  of  large  forceps  thrust  through 
the  inferior  lobe  of  the  right  lung.  There  was  but  Httle  haemorrhage. 
Kangaroo  tendon  used  for  tug  stitching.  The  suture  used  was  not  ex- 
actly the  tug  stitch,  but  the  one  devised  by  the  author.  It  is  a  com- 
bination of  the  tug  and  lace  sutures.  In  this  case,  the  wound  was 
completely  encircled  by  a  double  row  of  sutures.  Only  one  needle  was 
used.     (See  Section  on  Sutures  in  Part  I.) 

Autopsy  showed  complete  recovery,  and  repair,  leaving  a  small, 
hard,  white  cicatrix,  extending  through  the  lobe,  which  was  apparent 
to  the  sense  of  touch.  The  photograph  plainly  depicts  the  hard,  white, 
circumscribed  cicatrix.      (Plate  LXXIV.) 


Plate   LXXXV. 


Experiment  on  Lungs,  No.  33.  page  492. 


RECORD    OF   EXPERIMENTS  491 

20.  July  30,  1900. — Black  terrier,  ten  months  old;  weight,  12  pounds. 
The  left  lower  lobe  of  the  right  lung  was  punctured  and  lacerated, 
using  both  knife  and  finger.  Kangaroo  tendon  was  employed  to 
circumscribe  the  wound,  with  the  author's  combination  suture. 
Killed  dog  nine  days  after  the  operation. 

Autopsy  showed  perfect  and  uneventful  recovery,  with  complete 
repair  of  the  lung.  The  photograph  shows  how  perfectly  the  wound 
united,  and  the  very  shght  cicatrix  formed.     (Plate  LXXV.) 

21.  July  30,  1900. — White  terrier,  ten  months  old;  weight,  15  pounds. 
At  5:30  A.M.  cut  away  one-third  of  the  inferior  lobe  of  the  right  lung, 
transversely;  using  kangaroo  tendon  to  whip-stitch  the  wound.  Killed 
dog  nine  days  after  the  operation. 

Autopsy  showed  complete  repair  of  the  stump,  as  seen  in  photo- 
graph.    (Plate  LXXVI.) 

22.  July  30,  1900. — Black  fox-terrier,  one  year  old;  weight,  15 
pounds.  Punctured  inferior  lobe  of  right  lung,  and  tug-stitched  in  a 
circle  around  the  perforation.  The  Bell  suture  was  used  in  tug-stitch- 
ing, and  the  sutures  were  passed  through  the  entire  thickness  of  the 
lobe.     Killed  dog  nine  days  later.     (Plate  LXXVU.) 

Autopsy  showed  perfect  union,  with  a  light-colored  cicatrix. 

23.  July  30,  1900. — Black  terrier  bitch,  one  year  old;  weight,  15 
pounds.  At  5:30  A.M.  cut  away  transversely  one-third  of  butterfly 
lobe  of  the  right  lung;  kangaroo  tendon  used  to  tug-stitch  the  wound. 
Killed  dog  August  9th. 

Autopsy. — There  was  perfect  repair  of  stump,  but  with  adhesions 
to  the  chest  wall,  at  the  point  of  normal  proximity,  at  time  of  maximum 
inflation. 

24.  July  30,  1900. — Mixed  fox-terrier  and  water-spaniel,  one  year 
old;  weight,  15  pounds.  Removed  one-half  of  the  middle  lobe  of  the 
right  lung.     Kangaroo  tendon  was  employed  in  suturing. 

Autopsy,  nine  days  later,  revealed  perfect  repair  and  union  of  stump. 
The  photograph  shows  appearance  of  lungs.     (Plate  LXXVUI.) 

25.  July  30,  1900. — Yellow  cur  bitch,  one  and  a  half  years  old; 
weight,  18  pounds. 

Right  upper  lobe  brought  into  opening  in  the  chest  wall  and  cut  off. 
Stump  was  fixed  in  the  intercostal  space,  with  silk-worm  gut.  The 
cutaneous  structures  were  sutured  over  it.     Killed  dog  August  9th. 

Autopsy  showed  perfect  recovery  and  union  (Plate  LXXIX),  with 
stump  firmly  adherent  to  the  chest  wall,  at  point  of  fixation. 

26.  July  30,  1900. — Black  and  white  cur  dog,  one  year  old;  weight, 
60  pounds. 

Removed  inferior  lobe  of  right  lung,  after  silk-worm  gut  had  been 
applied  for  ligature.  The  ligature  became  dislodged,  and  death  ensued 
within  two  minutes. 

Autopsy,  ten  minutes  later,  showed  pleural  cavity  filled  with  blood. 


492  THE  SURGERY  OF  THE  LUNGS 

The  vessels  and  bronchus  were  open.     Death  was  due  to  haemorrhage, 
as  a  result  of  carelessness.     (Plate  LXXX.) 

27.  July  30,  1900. — White  bulldog,  two  years  old;  weight,  45  pounds. 
Same  operation  with  the  same  results  as  in  No.  26. 

Death  caused  by  haemorrhage,  due  to  carelessness.    (Plate  LXXXI.) 

28.  July  30,  1900. — Black  dog,  two  years  old;  weight,  50  pounds. 
One-half  of  upper  lobe  of  right  lung  was  cut  away,  transversely,  using 
silk  to  whip-stitch.  Silk  was  also  used  to  ligate  both  vessels,  and 
bronchus.     Dog  died  August  9th. 

Autopsy  showed  right  side  of  pleural  cavity  tilled  with  bloody  serum. 
Death  probably  the  result  of  stump  opening  in  line  of  suture.  This 
was  caused  by  imperfectly  applied  ligature.     (Plate  LXXXII.) 

29.  August  6,  1900. — Fox-terrier,  six  months  old;  weight,  12  pounds. 
The  inferior  lobe  of  right  lung  was  split  and  returned  to  the  pleural 
cavity,  without  suturing  the  divided  portion  of  the  lung.  The  chest 
opening  was  closed  with  silk-worm  gut.     Killed  dog  August  14th. 

Autopsy  showed  perfect  repair  of  lung,  with  adhesion  to  chest  wall, 
at  the  point  of  normal  proximity,  at  time  of  maximum  expansion. 

30.  August  2,  1900. — Maple  cur,  two  years  old;  weight,  18  pounds. 
Removed  upper  lobe  of  right  lung,  after  resecting  the  fifth  and  sixth 
ribs.  Kangaroo  tendon  used  for  ligating,  by  transfixing  at  base  of  lung. 
Killed  dog  August  14th. 

Autopsy  showed  repair  of  stump  to  be  perfect.     (Plate  LXXXIII.) 

31.  August  2,  1900. — Black  dog  (No.  i),  one  year  old;  weight,  20 
pounds.  At  2  P.M.,  ligated  base  of  right  wing  of  butterfly  lobe,  by 
transfixing  with  kangaroo  tendon.     Killed  dog  August  14th. 

Autopsy  revealed  perfect  repair,  with  kangaroo  tendon  covered  with 
plastic  material.     (Plate  LXXXIV.) 

32.  August  2, 1900. — 3  P.M. — Black  dog  (No.  2),  one  year  old;  weight 
20  pounds.  Applied  tug-stitch,  for  three  inches  across  the  upper  lobe, 
through  the  entire  thickness  of  the  lung,  with  silk.  Killed  dog  August 
9th. 

Autopsy  showed  the  silk  suture  almost  entirely  covered  with  new 
tissue.     Recovery  and  repair  perfect. 

33.  August  2,  1900. — Yellow  black-nosed  dog;  two  years  old;  weight, 
25  pounds. 

Applied  sutures,  using  silk  ligature,  across  the  upper  right  lobe  of 
the  lung,  near  its  centre.  (The  herring-bone  suture  was  the  one  em- 
ployed here.)     Killed  dog  August  9th. 

Autopsy  showed  perfect  recovery  from  operation,  and  repair  of  lung. 
The  end  of  the  silk  was  exposed.     (Plate  LXXXV.) 

34.  August  2,  1900. — Bobtail  dog,  ten  months  old;  weight,  14  pounds. 
Removed  upper  lobe  of  right  lung,  using  kangaroo  tendon  for  three  liga- 
tures at  the  base.  The  kangaroo  tendon  was  used  to  transfix  the  base. 
The  first  ligature  was  placed  around  all  the  vessels;  the  second  occluded 
the  bronchus,  and  the  third,  the  lung  ti.s.sue.     Killed  dog  August  9th. 


Plate    LXXXVI. 


Experiment  on  Lungs,  No.  34,  page  492. 


RECORD   OF   EXPERIMENTS  493 

Autopsy  showed  perfect  recovery,  and  repair  of  stump.  (Sec 
Plate  LXXXVI.) 

35.  August  2,  1900. — Black  dog,  two  years  old;  weight,  25  pounds. 
Lower  lobe  of  right  lung  was  split  perpendicularly,  and  sutured  with 
kangaroo  tendon,  using  a  relief  suture  (mattress).  Killed  dog  August 
14th. 

Autopsy  showed  complete  recovery,  and  perfect  repair.  Point  of 
re})air  adherent  to  chest  wall  at  the  point  of  proximity,  at  time  of  maxi- 
mum inflation. 

36.  August  2,  igoo. — Fox  bitch,  one  and  one-half  years  old;  weight, 
18  pounds. 

Resected  the  sixth  rib  on  the  right  side,  leaving  the  pleural  cavity 
open  fifteen  minutes.  The  mediastinum  was  then  incised  near  the 
heart,  thus  allowing  the  left  lung  to  recede.  Both  cavities  were  ex- 
posed to  atmospheric  pressure  for  five  minutes.  The  opening  in  the 
chest  wall  was  covered  by  the  hand.  Respiration  was  again  estab- 
lished, and  lungs  allowed  to  recede.  There  was  more  or  less  motion 
of  the  lungs  while  the  chest  remained  open.  At  the  end  of  twenty-five 
minutes  the  opening  of  the  chest  wall  was  closed  with  silk-worm  gut, 
and  dog  sent  to  his  kennel.     Killed  dog  August  14th,  4  p.m. 

Autopsy  showed  nothing  abnormal.  The  mediastinum  was  closed, 
and  repair  complete. 

37.  August  2,  igoo. — Dark  brown  dog,  eight  months  old;  weight, 
16  pounds.     This  dog  died  as  the  chest  was  being  opened. 

Autopsy  gave  only  negative  results.  No  cause  of  death  discovera- 
ble; probably  due  to  ether.  All  the  organs  were  normal  and  in  good 
condition. 

38.  August  6,  igoo. — Common  dog,  eight  months  old;  weight,  12 
pounds.  Apex  of  lower  lobe  of  right  lung  cut  away.  The  bleeding 
vessels  were  torsioned,  and  the  lung  returned  to  the  pleural  cavity,  with- 
out the  lung  tissues  being  sutured.     Killed  dog  August  14th. 

Autopsy  showed  complete  recovery,  and  repair  of  the  lung,  but  the 
lung  was  adherent  to  the  chest  wall  at  point  of  normal  proximity,  at 
time  of  maximum  expansion. 

39.  August  6,  igoo. — Long-haired  dog,  one  year  old;  weight,  25 
pounds.  Removed  butterfly  lobe,  using  kangaroo  tendon  for  each  liga- 
ture, at  base.  The  first  ligature  was  placed  around  the  blood-vessels; 
the  second  around  the  bronchus;  the  third  was  placed  about  the  lung 
tissues. 

On  the  tenth  of  August  the  dog  attempted  to  escape,  and  the  attend- 
ant seized  him  rather  roughly  by  the  back.  This  caused  the  chest  wall 
to  open;  it  was  not  again  closed.     The  dog  died  at  6  a.m.,  August  13th. 

Autopsy  showed  the  stump  in  a  good  state  of  repair.  The  pleural 
cavity  contained  some  pus,  the  result  of  suppurative  pleuritis.  The 
bronchus  and  blood-vessels  were  found  occluded.     The  infection  prob- 


494  THE  SURGERY  OF  THE  LUNGS 

ably  occurred  after  the  reopening  of  the  chest  cavity,  which  was  pur- 
posely left  open.     There  were  no  adhesions  of  the  pleura. 

40.  August  6,  1900. — Black  bitch,  two  years  old;  weight,  27  pounds. 
Divided  the  fifth  intercostal  artery,  on  the  right  side,  to  allow  three  or 
four  ounces  of  blood  to  escape  into  the  pleural  cavity.  The  chest  wall 
was  closed  with  silk-worm  gut.     Killed  dog  August  14th,  4  p.m. 

Autopsy  showed  complete  recovery.  There  were  no  clots,  fluid,  or 
adhesions  found  in  the  pleural  cavity. 

4:.  August  6,  1900. — Hound  bitch,  five  months  old;  weight,  10 
pounds.  Inferior  lobe  of  right  lung,  split,  and  returned  to  the  pleural 
cavity,  without  suturing  the  lung.     Killed  dog,  August  14th. 

Autopsy  showed  union  to  be  complete.  The  end  of  the  lung  was 
adherent,  at  its  point  of  proximity,  to  the  chest  wall,  at  time  of  maxi- 
mum expansion. 

42.  August  14,  1900. — Chestnut  dog,  one  year  old;  weight,  27 
pounds.  Resected  the  fifth  and  sixth  ribs  on  the  right  side.  Ligated, 
with  silk,  the  vessels  at  base  of  the  upper  lobe  of  the  right  lung.  A  silk 
ligature  was  placed  also  about  the  bronchus.  Removed  two  ounces 
of  clots  from  the  pleural  cavity,  which  was  open  twelve  minutes.  Death 
occurred  just  as  the  cavity  was  being  closed. 

Autopsy  revealed  no  cause  of  death.  It  was  probably  due  to  ether. 
Neither  air  nor  water  could  be  forced  through  stump,  proving  that 
bronchus  and  vessels  were  occluded. 

43.  August  14,  1900,  3  P.M. — Black  dog,  six  months  old;  weight, 
24  pounds.  Folded  upper  part  of  right  lung  upon  itself,  and  sutured 
with  silk,  using  the  interrupted  suture.  This  was  done  in  order  that 
the  visceral  pleura  might  become  adherent.     Dog  died  August  17th. 

Autopsy  showed  the  lung  in  good  condition.  No  fluid  in  cavity,  nor 
any  cause  of  death  discoverable.  The  dog  had  distemper  at  time  of 
operation,  and  but  little  attention  was  given  him. 

44.  August  14,  1900. — Black  dog,  one  year  old;  weight,  18  pounds. 
Divided  sixth  rib  on  right  side,  incised  inferior  lobe,  transversely,  to 
one-third  of  its  thickness.  Sutured  with  kangaroo  tendon,  employing 
the  mattress,  or  quilted  suture.     Killed  dog  August  21st. 

Autopsy. — Lobe,  at  point  of  incision,  adherent  to  the  chest  wall,  at 
a  point  corresponding  to  the  point  of  normal  proximity  at  time  of  maxi- 
mum distention  of  the  lung.  The  kangaroo  tendon  had  broken  into 
several  pieces,  but  it  still  could  be  recognized. 

45.  August  14,  1900. — Brown  dog,  one  year  old;  weight,  18  pounds. 
Killed  dog  with  chloroform.  Removed  the  lungs,  and  injected  the 
bronchia  with  paraffin,  while  lung  was  in  water,  at  a  temperature  of 
one  hundred  and  twenty  degrees  F.  The  process  was  not  at  all  satis- 
factory, however,  as  the  paraffin  occluded  the  bronchioles  before  dis- 
tention was  complete. 

46.  August  14,  1900,  5  P.M. — White  bitch,  three  years  old;  weight. 


Plate  LXXXVII. 


Experiment  on  Lungs,  No.  46,  page  492. 


RECORD   OF   EXTERIMENTS  495 

40  pounds.  Amputated  the  upper  right  lobe.  Braided  silk  was  used 
as  a  ligature,  to  ocx'lude  the  bronchus  alone,  while  another  ligature,  of 
the  same  material,  was  used  to  occlude  the  blood-vessel;  each  ligature 
being  transfi.xed  at  base  of  the  lung  before  it  was  made  taut.  Killed 
dog  August  20th. 

Autopsy  showed  repair  of  stump,  practically  complete.  All  the 
vessels  were  found  to  be  occluded.     (Plate  LXXXVII.) 

47.  August  25,  1900. — Black  dog,  one  year  old;  weight,  15  pounds. 
Killed  dog  with  chloroform,  in  order  to  secure  the  lungs.  Injected 
bronchial,  arterial,  and  venous  systems  with  a  mixture  of  anilin,  starch, 
and  formalin.  Specimen  unsatisfactory,  owing  to  tuberculous  de- 
generation of  apex  of  the  superior  lobe  of  the  left  lung,  which  ruptured 
during  injection.  This  is  the  only  one,  of  the  series  of  fifty  dogs,  in  which 
any  signs  of  tuberculosis  were  found. 

48.  August  22,  1900. — Black  Newfoundland  dog,  five  years  old; 
weight,  50  pounds. 

Killed  dog,  in  order  to  secure  the  heart  and  lungs.  Injected  bron- 
chial, arterial,  and  venous  systems  with  starch  and  anilin,  in  formalin 
water  (one  per  cent.).  This  specimen  was  divided  with  the  knife, 
transversely,  making  seven  sections,  each  one  inch  thick.  Each  section 
was  photographed  separately,  as  shown  in  Plates  LVIII  to  LXIII. 

49.  August  27,  1900. — Hound  bitch,  three  years  old;  weight,  35 
pounds. 

Dog  killed  with  chloroform,  for  specimen.  Injected  with  starch 
and  anilin,  in  formalin  water,  with  satisfactory  results. 

50.  August  25,  1901. — Fox  terrier,  one  and  one-half  years  old; 
weight,  18  pounds.  Removed  entire  left  lung.  Dog  recovered  and 
lived,  with  no  ill  effects.     Killed  on  eighteenth  day. 


ANALYSIS  OF  TABLES 

An  examination  of  the  tables  reveals  the  fact,  that  most  of  the  deaths 
were  avoidable.  Seven  dogs  died  from  infection,  which  is  about  15.7 
per  cent.  Seven  dogs  died  from  haemorrhage  (secondary  and  primary), 
or  about  15.7  per  cent.  Lack  of  care  on  the  part  of  the  operator 
and  attendants  was  responsible  for  all  these  cases  of  infection  and 
haemorrhage. 

But,  as  stated  in  explanation  of  the  experiments  and  results  obtained, 
no  special  care  was  observed,  nor  were  any  antiseptics  used.  Some 
of  the  operations  were  performed  hurriedly,  and  the  operator  was  per- 
haps a  Httle  careless.  This  was  shown  by  the  autopsies.  In  one  case 
the  ligature  had  slipped,  in  another,  the  ligature  had  been  dislodged, 
because  the  tissues  broke  down  from  infection. 

All  this  could  have  been  avoided,  by  observing  the  principles  of 
modern  surgery. 

There  remain  only  three  deaths  to  be  taken  in  account,  in  arriving 
at  a  just  estimate  of  the  mortality  in  pulmonary  surgery. 

Of  these  three  cases,  one  was  due  to  pneumonia,  and  two  to  the 
anaesthetic.  This  case  of  pneumonia  was  probably  due  to  infection; 
hence  could  have  been  avoided.  It  is  also  a  question,  just  how  far  the 
operator  is  responsible  for  deaths  from  the  anaesthetic. 

It  will  also  be  noticed  that  the  majority  of  the  deaths  occurred  dur- 
ing the  early  part  of  the  series.  In  all  kinds  of  experimental  work  on 
the  living  subject,  there  are  numerous  practical  details  that  can  only  be 
solved  by  actual  experience.  So  in  this  series,  as  the  operator  gained 
experience  and  skill  in  this  work,  he  had  better  success.  The  needed 
experience  is  soon  gained. 

If  it  were  possible  to  repeat  these  experiments,  there  is  no  doubt 
that  the  mortality  would  be  greatly  reduced,  even  if  deaths  from  in- 
fection, etc.,  were  not  completely  eliminated. 


496 


ANALYSIS   OF   TABLES 


497 


SUMMARY  OF  RECOVERIES  AND  DEATHS 


RECOV- 
ERIES. 

DEATHS. 

PERCENT- 
AGE. 

From  infection  (average  length  of  life,  51-7 
davs) 

7 

2 

5 

I 
I 
2 

5 

14 
4 

10 

"     Haemorrhage,  primary  (died  on  the  table) 

"     Haemorrhage,  secondary  (average  length 

of  life,  three  days) — imperfect  ligature 

"     Pneumonia 

"     Accidental   opening  of   wound 

"     Anaesthetic       

2 

4 
54 
10 

Killed   for  autopsy  and  specimen 

Killed  for  specimen  of  normal  lung 

28 

23 

Number  of  operations 

46 
28 
18 

Number  of  recoveries 

Number  of  deaths 

STATISTICAL  REPORT  OF  LUNG  SURGERY  ON  FIFTY  DOGS 
(Experimental) 
Section  No.  i.  Unsuccessful  Results. 


CAUSE    OF    DEATH. 


TIME  LIVED. 


CONDITION   AT   DEATH. 


I 
2 

3 
4 
5 
6 

9 
12 

15 

17 

18 
26 

27 

28 
37 
39 

43 


Infective  pleurisy 

General  infection 

General  infection 

General  infection 

Secondary  hcemorrhage 

Infection 

Infection 

Imperfect  ligature 

Pneumonia 

Imperfect  ligature . 

Infection 

Haemorrhage 

Haemorrhage 

Secondary  haemorrhage 

Anaesthetic 

Accidental  opening   of 

wound 

Unknown  


ID  aays. 
4  days. 
9  days. 
2  days. 
2  days. 

days. 

days. 

days. 

days. 

days. 


Died  during 
operation. 

Died  during 

operation. 

3  days. 


7  days. 


Discharging  pus. 
Discharging  pus. 
Discharging  pus. 
Ligature  slipped. - 
Clot  in  cavity. 


-Clot  infected. 


Slough. 

Open  wound  (lung  stump). 


Had  distemper  at  time  of  ojiera- 
tion. 


498 


THE    SURGERY   OF   THE   LUNGS 


STATISTICAL    REPORT    OF    LUNG    SURGERY    ON  FIFTY    DOGS 

(Experimental) 
Section  No.  2.    Successful  Results. 


NO. 

WAS    KILLED   ON 

CONDITION. 

RECOVERY. 

7 

19th  day. 

Perfect  repair. 

Complete. 

8 

19th  day. 

Perfect  repair. 

Complete. 

10 

19th  day. 

Perfect  repair. 

Complete. 

II 

19th  day. 

Perfect  repair. 

Complete. 

13 

1 6th  day. 

Perfect  repair. 

Complete. 

14 

1 6th  day. 

Perfect  repair. 

Complete. 

16 

14th  day. 

Perfect  repair. 

Complete. 

^9 

15th  day. 

Perfect  repair. 

Complete. 

20 

loth  day. 

Perfect  repair 

Complete. 

21 

loth  day. 

Perfect  repair. 

Complete. 

22 

loth  day. 

Perfect  repair. 

Complete. 

23 

loth  day. 

Perfect  repair. 

Complete. 

24 

loth  day. 

Perfect  repair. 

Complete. 

25 

loth  day. 

Perfect  repair. 

Complete. 

29 

8th  day. 

Repair  going  on 

Complete. 

30 

12th  day. 

Perfect  repair. 

Complete. 

32 

7th  day. 

Repair  progressing. 

Complete. 

31 

12th  day. 

Perfect  repair. 

Complete. 

33 

7th  day. 

Good. 

Going  on. 

34 

12th  day. 

Perfect  repair. 

Going  on. 

35 

1 2th  day. 

Perfect  repair. 

Complete. 

36 

12th  day. 

Perfect  repair. 

Complete. 

38 

8th  day. 

Perfect  repair. 

Complete. 

40 

8th  day. 

Perfect  repair. 

Complete. 

41 

8th  day. 

Perfect  repair. 

Complete. 

44 

7th  day. 

Repair  progressing. 

Complete. 

45 

6th  day. 

Repair  progressing. 

Complete. 

46 

Killed    in    order    to    se- 
cure lung  for  other  pur- 
poses. 

47 

Ditto. 

48 

Ditto. 

49 

Ditto. 

50 

1 8th  day. 

Perfect  repair. 

Complete. 

INDEX 


Abnormalities,  of  bronchi,  289 
of  chest,  290 

causes  of,  289 
of  diaphragm,  289-292 
of  ductus  arteriosus,  42,  47 
of  foramen  ovale,  40,  42 
of  heart,  abnormal  number  of  cav- 
ities, 47,  78 

extrophy  of,  291 
of  interauricular  openings,  42 
of  interventricular  openings,  41-46 

effect  of,  41,  42 

position  of,  41 

varieties  of,  41 
of  lung,  289-292 

aetiology  of,  289 

bibliography  of,  292 

cases  reported,  290 

diaphragmatic  hernia,  290 

three  lungs,  292 
of  mediastinum,   289 
of  pericardium,  289 
of  pulmonary  vessels,  289 
of  thoracic  viscera,  due  to,  289 
of  trachea,  292 
Abscess,  of  heart,  cases  reported,  202 

causes,  202 

outcome,  202 

position,  202 

varieties,  202 
of  lung,  aetiology  of,  358 

bibliography  of,  360 

cases  reported,  358 

caused  by  polypus,  403,  404 

differential  diagnosis,  399 

due  to  influenza  bacilli,  366 

forms  of,  366 

frequency  of,  358 

from  foreign  body,  341-343,  360 

most    frequent    complication    of, 
366 

most  frequent  location,  358 

opening  spontaneously,  360,   362 

operation  for,  312,  367 


Abscess  of  lung,   operated   on,  358- 
365,  368,  369 
operated  on  with  recovery,  358- 

360,   362-365,    368 
prognosis  of,  366 
relative  frequency  of  pneumonia 

following  incision  for,  366 
requiring  excision  of  lung,  359 
resulting  in  fistula,  359 
simulates  other  conditions,  365 
sputum  in,  365,  366 
symptoms  and  diagnosis,  365 
to  locate  after  incision,  367 
treated  by  injection  of  carbolic, 

360 
treated  surgically,  358-365 
treated  surgically  with  recovery, 

358-360,  362-365 
treatment  of,  313,  366 
tuberculous,    operated    on,    358, 
359,  361-363,  365 
Actinomyces,  animals  which  are  im- 
rnune,  235,  443 
description  of,  235 
granule  of,  appearance  of,  235,  442 
in  heart,  how  infected,  235 
possible  outcome  of,  235 
macroscopical  diagnosis,  235 
mode  of  infection,  235 
mycelium  of,  235,  442 
where  located  in  mouth,  442 
Actinomycosis,  bibliography  of,   445 
of  lung,  442 

appearance  of,  442 
cases  reported,  443 
cases    operated    on    and    results, 

.445 
clinical  diagnosis  of,  443 
mode  of  infection,  442 
mortality  of,  442 
mortality  of,  affected  by  surgery, 

442 
symptoms  of,  442 
treatment  of,  444 


49Q 


500 


INDEX 


Actinomycosis,   most  frequent  loca- 
tion of,  445 
spread  of,  442 
pus  in,  442 
Adrenalin,  action  of,  36 

in  shock,  36 
Agar-agar,  injected  into  pleural  cav- 
ity, 298 
Anatomy,  comparative,  10 
Aneurysm,  of  heart,  cases  reported, 
179,  180 
causes  of,  179 
position  of,  179 
symptoms,  179 
of  right  auricle,  124 
ventricular,  121 
Anthrax,  aetiology  of,  438 
in  animals,  437 
bacillus  of,  437 

geographical  distribution  of,  437 
in  heart,  22,"] 

incubation  period,  237,  438 
in  lung,  cases  reported,  438 
mode  of  infection,  237 
symptoms  of,  438 
Aorta,  abnormalities  of,  42-46 
aneurysm  of,  tied  off,  34 
of  fish,  8 
rupture  of,  123 
Aortic  arch,  11 
in  birds,  12 
in  crocodile,  11,  12 
in  mammals,  12 
Aortic  pressure,  25 
Apneumatosis,  see  Atelectasis 
Arteries,  abnormalities  of,  8 
in  birds,  12 

bronchial  course  and  communica- 
tions, 284 
distribution  of,  284 
origin  of,  284 
cardiac,  peculiarity  of,  17 
in  carp,  13 
in  cctacea,  12 
coronary,  20 

cause  of  rupture  of,  124 
ligation  of,  22 
differ  from  veins,  13 
in  domestic  ox,  12 
in  dugong,  12 
in  echidna,  12 
in  fishes,  13 
of  heart,  20 
in  hedgehog,  12 
in  kangaroo,  13 
in  lemur,  12 


Arteries,  in  lion,  12 
in  mammals,  12 

pulmonary,  expansion  of,  effect  on 
bronchi,  24 
abnormalities  of,  42-47 
distribution  of,  28 
transposition  of,  42 
respiration,  efifect  of,  on,  25 
in  sloths,  12 
Arterioles,  relaxation  of,  effect  of,  35 
Aspergillus,  445 
description  of,  235 
in  heart,  position  of,  235 
in  lung,  cases  reported,  446 
varieties,  235,  445 
varieties  described  and  compared, 
446 
Aspiration,    to   induce    heart   action, 

154 

of  pericardium,  248 
Atelectasis,  acquired,  causes  of,  405 

bibliography  of,  409 

cases  reported,  406 

complications  of,  406 

congenital,  405 

mechanism  of  collapse,  405 

most  common  cause,  408 

paralysis    of   pneumogastric    caus- 
ing, 408 

pathology  of,  408 

physical  examination  in,  407 

symptoms  and  diagnosis,  407 

treatment  of,  408 

value  as  evidence,  405 
Auricles,  contraction  of,  21 

fibroid  tumor  in,  213,  214 

independent  action  of,  22 

negative  pressure  in,  26 

rupture  of,  122,  123,  125 

sseptum  of,  formation  of,  40 

Bacilli,  bibliography  of,  243 
Bacillus,  aerogenes  capsulatus,  438 
«    in    appendicitis    and    strangula- 
tion, 439 
bibliography  of.  440 
in  heart  of  rabbits,  243 
in  intestine,  439 

relation  to  emphysematous  gan- 
grene, 439 
variation  in  action,  439 
anthracis,  437 
of  gangrene,  375 
oedematis  maligni.  438 
appearance  of  colonies  of,  236 
associated  with  tetanus,  237 


INDEX 


5(ji 


Bacillus,  ocdcmatis  nialigni,  in  heart, 

237 
location  of,  in  body,  237 
source  of  infection,  237 
where  found  in  nature,  438 
pneumonia.',  Friedlaender,  descrip- 
tion of,  440 
in  exudates,  440 
value  of,  in  diagnosis,  440 
tuberculosis,  440 
in  lesion,  440 
mode  of  infection,  440 
typhosus,  in  heart,  243 
in  lung,  441 
Benign  tumors,  treatment,  425 
Bibliography   of,    anatomy   of   heart, 
28 
anatomy  of  lung,  288 
abnormalities  of  lung,  292 
abscess  of  heart,  204 
abscess  and  bronchiectasis  of  lung, 

369 
actinomycosis,  445 
angeioma  of  heart,  217 
atelectasis  and  apneumatosis,  409 
bacilli,  239 

bacillus  aerogenes  capsulatus,  440 
calcification  in  heart,  199 
carcinoma  of  heart,  226 
carcinoma  of  lung,  435 
cardiac  aneurysm,   181 
cardiamorphia,  49 
cardioclasia,  125 
cardioliths,  194 
cardiorrhaphy,    cardiotomy,    heart 

sutures,  175 
cysticercosis,  462 
cysticercus,  2^3 
echinococcus,  228 
echinococcus  in  lung,  454 
ectocardia.  Si 
experimental    research    on    heart, 

37 
experimental  research  on  lung,  298 
fibroma  of  heart,  214 
foreign  bodies  in  lung,  350 
gangrene  of  heart,  212 
gangrene  of  lung,  383 
gunshot     lacerated     and      incised 

wounds  of  heart,  99 
gunshot  wounds  of  chest,  329 
hernia  of  lung,  395 
influence  of  trauma  on  lung,  298 
lacerated    and    incised    wounds    of 

lung,  339 
lipoma  of  heart,  216 


Bibliography    of,    malignant    tumors 
of  lung,  428 

miscellaneous,  of  heart,  243 

myxoma  of  heart,  218 

oedema  of  lung,  400 

oidium  albicans,  236 

operations  on  lung,  316 

paragonimus  Westermani,  459 

parasitic  fungi  of  heart,  236 

pneumonomycosis,  448 

pneumonotomy     and     anaesthesia, 
316 

polypi  of  heart,  220 

rhabdomyoma  of  heart,  218 

rupture  of  lung,  388 

sarcoma  of  heart,  224 

sarcoma  of  lung,  431 

syphilis  of  heart,  207 

syphilis  of  lung,  417 

trichina  spiralis  of  lung,  465 

tUfberculosis  of  heart,  239 
Blood,  coagulation  of,  27 
cause  of,  27 

color  of,  27 

endothelium  in  vessels,  loss  of,  ef- 
fect on,  28 

fibrin,  27 

effect    of    micro-organisms    on, 
28 

supply  of,  to  lungs,  286 

volume    of,    effect    of    diminished 
watery  element  on,  27 
effect  of  haemorrhage  on,  27 
effect  of  food  on,  27 
effect    of   increased    watery    ele- 
ment on,  27 
Blood  pressure,  adrenalin,  effect  on, 
36 

in  heart,  25 

low,  effect  on  heart  of,  35 

negative,  25 

opening  thoracic  cavity,  effect  on, 
26 

positive,  25 

in  veins,  26 
Blood  vessels,  acupressure,  value  of, 

305 
ligation  of,  history  of,  300-305 
methods     to     stop     bleeding     of. 

300-304 
rete  mirable,  see  Rete  mirabile 
torsion  of,  value  of,  305 
Branchial  arches,  in  ceratodus,  11 
in  frog,  ri 
in  Icpidosirens,  II 
in  sharks,   il 


502 


INDEX 


Bronchial  polypus,  see  polypus 
Bronchiectasis,  per  cent,  of  recover- 
ies after  operation,  276 
Bronchioles,  284 
Bronchus,  arteries  of,  see  Arteries 

description  of,  284 

infundibula  vesica,  283 

muciparous  ducts  of,  284 

muscular  coat,  function  of,  284 

sscptum  bronchiale,  position  of,  283 

sensibility  of,  285 

in  sheep,  283 

operations  on,  see  Operations 
Bulbus  arteriosus,  11 

Calcification    in    heart,    cases    re- 
ported, 198 

causes,  198 

position  of  deposit,  198 
Capillaries  of  lung,  295 
Carcinoma,  see  Tumors 
Cardio-pneumatic  movement,  24 
Charcoal  and    coal,   in  lungs,   effect 

of,  343 

Chondroma,  see  Tumors 

Circulation,    arterial,    effect    of    res- 
piration on,  25 
artificial  respiration,  effect  of,  on, 

in  batrachian,  14 

change  at  birth,  8 

coronary,  effect  of,  on  heart,  35 

in  crocodiles,  15 

in  Crustacea,  9 

in  fish,  14,  15 

fcetal,  persistence  of,  46 

foramen   ovale,   patency   of,   effect 

on,  41 
in  frogs,  11 
interventricular    openings,     effects 

of,  on,  42 
in  lepidosiren,  15 
in  monoptcrus,  15 
l)ortal,  13 

renal,  in  batrachians,  13 
in  reptiles,  11 

respiration,  effect  of,  on,  295 
respiratory,  in  mollusca  and  Crus- 
tacea, 9 
time  required  for,   10 
vasomotor  collapse,  effect  on,  35 
in  vertebrates,  14 
Concretions  in  heart,  cases  reported, 
192 

as  foreign  bodies,  192 

fibrous,  192,  193 


Concretions  in  heart,  origin  of,   192 

varieties,  192 
Conus  arteriosus,  atresia  of,  46 

stenosis  of,  45 
Coronary    arteries,    abnormal,    num- 
ber of,  42 
obstruction  of,  effect  of,  48 
Crustacea,  circulation  in,  9 
Cyanosis,  42,  43 
Cysticercosis   of  lung,  460 
bibliography  of,  462 
symptoms,  diagnosis,  and  treat- 
ment of,  461 
Cysticercus,  in  animals,  460 
bibliography,  233 
description  of,  460 
in  heart,  cases  reported,  233 

frequency  of,  233 
in  lung,  460 

in  man,  most  frequent  location,  231 
in  meat,  appearance  of,  461 
mode  of  infection  of  lung,  461 
organs  invaded  by,  460 
sources  of  infection,  232,  460 
taenia  saginata,  description  of,  231 

in  beef,  22,2 
taenia  solium,  description  of,  232 
in  urine,  461,  462 

Dermoids,  see  Tumors 
Dextrocardia,  47,  48,  77-79 
Diaphragm,     abnormalities     of,     see 
Abnormalities 
in  amphibia  and  lower  animals,  297 
in  fish,  249 
in  mammals,  297 
Displacements,  of  heart,  78 
acquired,  79,  80 
causes  of,  yj,  79,  80 
congenital,  77 
hernia  of,  80 
symptoms  of,  78 
transposition  of,  77 
Ductus  arteriosus,  12 
abnormalities  of,  42-47 
in  cryptobranchus,  12 
Ductus  Cuvieri,  in  fish,  14 
Dugong.  heart  of,  8 
Dyspnoea,  effect  of,  on  heart,  25 

EcHiNococcus,  227 
cXtiology,  227,  449 
appearance  in  meat.  227 
bibliography  of,  228 
bibliography  of,  in  lung,  454 
cyst  of,  outcome  of,  449 


INDEX 


503 


Echinococcus,      disease      in       man, 
caused  by,  449 
fluid  in  cyst,  composition  of,  449 
geographical  distribution  of,  449 
location  of,  449 
operation  for,  454 
to  prevent  infection,  454 
in  vein,  effect  of,  449 
in  heart,  cases  reported,  227 

form  and  position,  227 

frequency  of,  227 

mode  of  infection,  227 

possible  outcome,  227 
in  lung,  cases  reported,  450 

cyst  incised,  450 

diagnosis  of,  ^3 

frequency  of,  449 

mortality  aflfected  by  operation, 
450 

mortality  when  treated  by  punc- 
ture, 450,  451 

operated  on,  with  recovery,  450, 

451 

symptoms,  453 

treatment  of,  453 

variety  of  cyst  in,  450 
Ectocardia,  cases  reported,  77 
Ectopia  cordis,  77 
Electricity,   to    induce    heart   action, 

153 
Emphysema,  in  wounds  of  lung,  335 
Endocardium,  description  of,  16 
Entozoa,  in  heart,  cases  reported,  228 
Experimental  research,  heart  action, 
induced,  261 
analysis   of   tables   relative   to   ex- 
periments on  dog,  496 
deductions  from,  474 
on  heart  of  dog,    caution  against 
much    manipulation    of    heart, 

253 

efifect  on  heart  of  contraction  of 
lung,  253 

ligation  of  coronary  artery,  re- 
sult of,  259 

needle  puncture,  result  of,  261 

operative  technique  in,  250 

rapidity  of  coagulation  of  blood, 
252 

record  of  experiments,  262 

remarks  on  experiments,  258 

suturing  heart,  255-257 

treatment  of  haemorrhage  in,  251 
on  lungs  of  dog,  conclusions  re- 
garding, 472 

record  of  experiments,  487-495 


Experimental  research,  tabulated  re- 
port, 497,  498 
vessels  injected,  472 
relations,  lungs  and  heart  of  dog, 
471 

Fixation    of    chest,    value    of,    in 

wounds  of  lung,  339 
Foramen  ovale,  at  birth,  8 
formation  of,  40 
patency  of,  40-44,  46-48 
cyanosis  in,  42 
cause  of,  40 
Foreign  bodies,  in  heart,  95,  97,  98, 
189 
cases  reported,  189 
concretion,  192 
effect  on  life,  189 
most  frequent  position,  189 
variety  of  articles  found,  189,  190 
in    lung,    abscess    resulting    from, 

.341-343 
bibliography  of,  350 
calcareous    bodies,     size,     form, 

color,  and  composition,  342 
cases  reported,  341 
frequency  on  left  side,  cause  of, 

349 

gangrene  resulting  from,  342 

laryngotomy  for,   345.   346 

opinions  as  to  operation  for,  345 

paths  of  escape  of,  341 

physical  signs  of,  347 

position,    change    of,    in    expan- 
sion and  contraction,  341 

records    of   miscellaneous   cases, 

344 
short  record  of  1,000  cases,  344 
simulating  tuberculosis,  344 
symptoms  of,  346 
tabulated  cases  referring  to  treat- 
ment, 344-346 
tracheotomy  for,  343-346 
treatment  for,  348 
variety  of  articles  found,  241-244 
in  pericardium,  93 
Fossa  ovalis,  10 

in  kangaroo,  il 
Frog,  heart  of,  11 

Gall  bladder,  obliteration  of,  77 
Ganglia,  cardiac,  19 

efifect  of  injury  to,  19 
inferior  cervical,  17 
intra-cardiac,  20 
efifect  of  opium  on,  20 


504 


INDEX 


Gall    bladder,    effect    of    stimulation 
on,  23 

formation  of,  20 

position  of,  20 
in  lungs,  287 

automatic  pulmonary,  297 
middle  cervical,  17 
peripheral,  297 
superior  cervical,  17,  18 
sympathetic,  17 
Wrisberg's,  18 
Gangrene,  of  heart,  212 

cases  reported,  212 
of  lung,  aetiology  of,  375 

bacillus  of,  375 

bibliography  of,  382 

cases  reported,  376 

differential  diagnosis,  399 

forms  of,  375 

mortality  of,  376,  377 

most  frequent  location,  367,  375 

operated  on,  376-380,  382 

operated  on,  with  recovery,  376, 
377-3^2 

operation  for,  381 

pathology  of,  380 

recoveries,  per  cent,  of,  after  op- 
eration, 276 

symptoms  and  diagnosis  of,  380 

treated  with  creosote,  380 

treatment,  313 

various  causes  of,  342,  376,  403 

H^MOPERiCARDiUM,     Symptoms    of, 

334    . 
Haemoptysis,     polypi     in     bronchia, 
causing,  402 
in  wounds  of  lung,  334 
possible  causes,  335 
Haemorrhage,  in  wounds  of  lung,  334 

treatment  of,  338 
Heart,  abnormalities  of,  see  Abnor- 
malities 
abscess  of,  see  Abscess 
absorption  of  fluid  by,  249 
action,  21 

external  pressure,  effect  of,   on, 

23 
extracardiac    nerve    centres,    ef- 
fect of,  on,  24 
relation  to  respiration,  24 
stopped,  23 
adrenalin,  effect  of,  on,  37 
in  amphioxus,  ri 
aneurysm  of,  see  Aneurysm 
aspiration  of,  32 


Heart,  aspiration,  abscess  cavity  of, 
98,  203 

atrophy  of,  effect  on  size,  41 

of  batrachians,  11 

beat,  mechanics  of,  20 

benign  tumor  of,  see  Tumors 

of  birds,  shape  of,  11 

blood  vessels  of,  16,  17,  20 

calcification,  see  Calcification 

cavities  of,  9 

capacity  of,  10 

of  chelonian,  shape  of,  11 

connective  tissue  of,  16 

contraction  of,  reversed,  20 

displacements    of,     see     Displace- 
ments 

of  dugong,  8,  II 

dyspnoea,  effect  of,  on,  25 

of  elasmobranchii,  11 

embryonic,  7,  8 

endocardium,  16 

energy  expended  by,  during  nor- 
mal lifetime,  26 

energy  expended  by,  in  24  hours, 
26 

excised,  rhythm  of,  22 

of  fish,  7,  8,  II 

foreign    bodies    in,    see     Foreign 
bodies. 

fossa  ovalis  of,  10 

of  frog,  II 
contraction,  after  death  in,  22 

gangrene  of,  see  Gangrene 
of  higher  vertebrates,  8 

hydatids  of,  operation  for,  146 

incisions  of,  effect  of,  22,  23 

inherent    force,    causing    contrac- 
tion, 21 

impulse  beat,  where  detected,  21 

of  invertebrates,  7 

of  lancelet,  11 

malformations  of,  see  Abnormali- 
ties 

mammalian,  function  of,  9 

muscle  corpuscle  of,  16 

muscular  tissue  of,  16 

needle  removed  from,  97,  146 

needle  puncture  between  ventricles, 
effect  of,  on,  32 

nerves  of,  17 

non-penetrating   gunshot   wounds, 
effect  on,  33 

operations  on,  cases  reported,  156- 
169 

operation  first  attempted,  146,  147 

position  of,  9 


INDEX 


505 


Heart,  pressure,  effect  of,  on,  249 
pressure  in  pericardium,  effect  on, 

32 
pressure  on,  from  pericardial  fluid, 

249 
puncture  of,  31 
puncture  of,  effect  on,  32,  33 
trauma,  effect  of,  on  muscle  fibres 

of,  33 
reaction  to  stimuli  in  higher  mam- 
mals, 23 
reflex  inhibition  of,  24 
relation  to  lungs,  9 
in  reptilia,   10 
resuscitation,  153 
rhythm  of,  when  excised,  22 
rhythmic  contraction  of,  32 
in  rigor  mortis,  24 
rupture  of,  see  Rupture 
shape  of,  9 

stimulated  by  needle,  22 
suture  of  wounds  of,  33 
sutures  of,  see  Sutures 
suturing  of,  possibilities  of,  32 
syphilis  of,  see  Syphilis 
of  teleosteans,  11 
terminology  of,  5 
of  tortoise,  contraction  after  death, 

22 
walls  of,  10 
weight  of,  9 
wounds  of,  see  Wounds 
Heart  action,  to  induce,  see  Resusci- 
tation 
Hernia,  of  lung,  390 

acquired,  some  causes  of,  392 

bibliography  of,  395 

cases  reported,  391 

in  civil  war,  393 

congenital,  393 

diaphragmatic,   390,   393 

differentiated  from,  390 

frequency  of,  391 

indication  for  operation  for,  391 

operated  on,  276,  392,  393 

with  recovery,  276,  392,  393  " 
recoveries    after    operation,    276, 

392.  393 
relative  frequency  right  and  left 

lung,  391 
respiration,  effect  of,  on,  394 
results,  if  not  reduced,  390 
symptoms  and  diagnosis,  394 
traumatic,  393 
treatment,  391-394 
Hernia,  usual  cause,  390 


Hydatid    cyst,    of    lung,    treatment, 

313 
Hypertrophy,     of     heart,     muscular 

fibres  in,  33 
Hypoglossal,  formed  by,  19 

Incision,  of  heart,  caution  in,  20 
Infusion  of  saline  to  stimulate,  36 
Injuries,  see  Wounds 
Interventricular  sseptum,  abnormali- 
ties of,  see  Abnormalities 

Laryngotomy,    for    foreign    bodies, 

345,  346 
Ligatures    and    sutures,    application 
of,  in  lung  tissue,  480 
first  used,  300 

history   of,   adhesive   inflammation 
due  to,  303 
animal     ligature     first     used     in 

America,  302 
catgut  first  used,  300 
double  ligatures  first  used,  300 
ends  first  cut  short,  302 
filo-pressure,  305 
materials  used,  300-302 
methods   of  ligating   arteries   of 

chest,  307 
needle  used,  301 
to  prevent  cutting,  301 
vessels  ligated,  300,  301 
materials  compared,  303-306 
non-absorbable,   effect   on  vessels, 

304 
Liver,    abnormalities    of,    with    dis- 
placed heart,  77 
Lung,  atelectasis,  and  apneumatosis, 
see  Atelectasis. 

abnormalities  of,  see  Abnormalities 

alveoli  of,  description  of,  285 

bibliography  of  anatomy  of,  288 

in  birds,  287 

blood  supply  to,  286 

capillary  circulation  of,  in  frog,  286 

capillary  circulation  of,  in  man.  2S6 

capillary  circulation  of,  in  reptilia, 
286 

cicatrices  of,  effect  of,  287 

collapse  of,  see  Atelectasis 

description  of,  282 

of  dog,  471 

effect  of  pinching,  297 

effect  of  trauma  on,  298 

endosmosis  of  gases,  296 

to  fix,  injection  of  fluid  into  pleural 
cavity,  298 


5o6 


INDEX 


Lung,  foreign  bodies  in,  see  Foreign 
bodies,  341 

gangrene  of,  see  Gangrene 

hernia  of,  see  Hernia 

influence  of  trauma  on,  bibliogra- 
phy of,  298 

injuries  of,  see  Wounds 

lymphatics  of,  285,  286 

in  monkeys,  283 

nerves  of,  course  of,  287 

nerve  plexuses  of,  formed  by,  289 

operations  on,  see  Operations 

pigment  in,  285 

pleural  covering,  see  Pleura 

respiration  begins  right  side,  283 

retraction    of,    efifect    on    haemor- 
rhage, 477 

rhythm  of,  controlled  by,  297 

rupture  of,  see  Rupture 

in  snake,  287,  290 

sutured,  333 

syphilis  of,  see  Syphilis 

terminology,  279 

tumors  of,  see  Tumors 

of    water-dog    (necturus    latera- 
lis), 287 

wounds  of,  see  Wounds 
Lymphatics,  of  lungs,  285,  286 
Lymphoma,  see  Tumors 

Malignant    oedema,    tissues    espe- 
cially affected,  438 
Malignant  tumors,  see  Tumors 
Manipulation,   heart  action   induced 

by,  153,  154 
Mediastinum  obliterated,  289 
Mollusca,  circulation  of,  9 
Muciparous  ducts,  of  bronchi,  284 
Mycosis,  of  heart,  234 

cases  reported,  234 

position  of  growth,  234 
Myxoma,  see  Tumors 

Needling,  to  stimulate  heart,  154 
Nerves,  cardiac  plexus,  17,  18 

of  heart,  17,  18 

plexus  cardiacus,  18 

pneumogastric,   17,  18 

pneumogastric,  to  heart,  17 

pulmonary    plexuses,    formed    by, 
285,  286 

sympathetic,  to  heart,  17 

sympathetic,  to  pulmonary  plexus, 
285 

vagus,  to  pulmonary  plexus,  285 


Nerves,  vasomotor  collapse,  35 
vasomotor,  shock,  34,  35 

CEdema,  definition  of,  397 
of  lung,  aetiology  of,  397 
bibliography  of,  400 
cases  reported,  397 
caused   by  hgemorrhagic  infarct, 

.398 

differential  diagnosis  of,  397-400 

division  of  vagi,  efifect  on,  398 

secondary  to  nephritis,  397 

sputum  in,  400 

symptoms  and  diagnosis,  398 

treatment  of,  399 
Oidium  albicans,  bibliography  of,  236 
description  of,  236 
in  heart,  236 
in  lung,  448 
Operations,  for  abscess  of  lung,  367 
bronchotomy,  309 

indications  for,  309 

technique  of,   348 
for  echinococcus  in  lung,  454 
for  foreign  bodies  in  lung,  348 
for  gangrene  of  lung,  381 
on  heart,  experimental,  for  mitral 
stenosis,  33 

for  hydatids,  146 

cases  reported,  156-169 

suturing,   33,  255-257 
for  ligation  of  bronchus,  476 
laryngotomy,    for   foreign    bodies, 

345,  346 
pneumocele,    treated    by    excision, 

331 
pneumonectomy,  308 
indications  for,  308 
pneumonopexy,  308 
pneumonorrhaphy,  308 
pneumonotomy,  anaesthesia  in,  314 
cases  reported,  310,  311 
indorsed,  333 
sterilization  in,  314 
technique  of,  313-315 
for  tuberculosis  abscess,  358,  359, 
361 
tracheotomy    for    foreign    bodies, 

343-346,  348 
for  trichina  spiralis  in  lung,  464 
on  lung,  435 
amount   of   tissue   to    be    incor- 
porated in  ligature,  476 
anaesthesia  in,  314 
for  aseptic  lesions,  mortality  of, 
312 


INDEX 


507 


Operations,    on    !ung,    bibliography 
of,  316 
cases  reported,  308,  309 
closing    chest    not   advisable    in, 

477 

drainage  in^  476 

excision,  297,  309 

excision  with  recovery,  309 

expansion,  when  chest  wound 
closed,  477,  481 

extirpation,  297 

forceps,  kind  to  be  used  in,  477 

incision  in,  475 

for  hydatid  cyst,  mortality  of, 
312 

haemorrhage  in,  if  uncontrolla- 
ble, treatment  of,  475 

methods    of    dividing    tissue    in, 

311 
needle  to  be  used  in,  480 
removal  one  or  more  lobes,  re- 
sults of,  479 
to  secure  vessels  in,  481 
septic  lesions,  mortality  in,  312 
suture  material  used  in,  308 
sutures  and  ligatures  in,  480-483 
tearing  versus  cutting  in,  476 
technique  of,  312 
treatment  of  stumps  in,  481 
Osteoma,  see  Tumors 

Paragonimus  Westermani,  aetiology 

of,  457 

in  animals,  457 

in  brain,  457 

cases  reported,  457 

frequency   of,   in  Japan   and   For- 
mosa, 457 

geographical  distribution  of,  457 

introduced  into  this  country,  458 

location  in  man,  234 

in  lung,  457 

bibliography  of,  459 
extension  of  infection,  458 

mode  of  infection,  234 

sputum  in,  458 

symptoms  and  diagnosis  of,  458 

treatment  of,  459 

and  tuberculosis,  234,  457 
Pericardium,  abnormalities  of,  289 

absorption  of  fluid  by,  249 

aspiration  of,  248 

description  of,  15 

in  elasmobranchii,  II 

fibrous  layer  of,  15 

in  fish,  249 


Pericardium,    historical    surgery    of, 
152 

in  myxinoid  fishes,  11 

relation  to  heart  and  vessels,  9 

serous  layer,  15 

shape  of,  9 

sutured,  96 

opened,  34 
Peritonaeum,  in  elasmobranchii,   1 1 

in  myxinoid  fishes,  11 
Pigment,  in  lungs,  285 
Plates,  description  of,   I  and   LVll- 

LXIII,  484 
Plexus  cardiacus,  ganglia  of,  impor- 
tance in,  18 

formation  of,  18 

position  of,  18 
Pleura,  description  of,  282 

effusion    in,    caused    by    gunshot 
wound,  324 

in  lower  animals,  282 

lymph  stream  of,  282 
Pneumocele,  see  Hernia  of  lung 
Pneumogastric,  18 

branch  to  dura  mater,  19 

communication  with  other  nerves, 

19 
Pneumonectomy,  see  Operations 
Pneumoniae,  bacillus  of,  440 
foreign  body  causing,  343 
Pneumonomyces,  447 
Pneumonomycosis,   bibliography   of, 
448 
cases  reported,  in  lungs,  447 
lesions,  symptoms,  and  diagnosis, 

447 
Pneumonopexy,  see  Operations 
Pneumonorrhaphy,  see  Operations 
Pneumonotomy,  see  Operations 
Pressure,  to  induce  heart  action,  153, 

154 
Pulmonary  artery,  in  crocodilia,  11 
for  other  references,  see  Arteries 
Puncture,  relative  haemorrhage,  au- 
ricle and  ventricle,   33 

Reptilia,  heart  of,  10 

Respiration,     effect     of    trauma    to 

chest  on,  298 
Resuscitation,  methods  of,  153 
Rete  mirabile,  in  cetacea,  12 

in  domestic  ox,  12 

in  lepidosiren,  13 

in  osseous  fishes,  13 

in  porbeagle  shark,  13 

venous,  in  porpoise,  13 


5o8 


INDEX 


Rhabdomyoma,  see  Tumors 
Rupture,  of  aorta,  123,  124 
of  coronary  arteries,  124 
of  heart,  124,  125 

cases  reported,  120 

causes  of,  120 

fatty  degeneration  as  factor   in, 
120,  121 

formation  of  clots  in,  120 

position  most  frequent,  120 

spontaneous,  120-122 

varieties  of,  120 

from  violence,  123 

with  recovery,  121 
interventricular  sa;ptum,  123-125 
of  lung,  290,  386 

associated  with  fracture  of  ribs, 
388 

bibliography  of,  388 

cases  reported,  387 

variety  of  causes,  387,  388 

without  injury  to  chest,  386 
of  pericardium,  121 

Saline  solution,  to  induce  heart  ac- 
tion, 153 
infusion  of,  action  of,  36 
Sarcoma,  see  Tumors 
Septic  lesions,  of  lungs,  per  cent,  re- 
coveries after  operation,  277 
Shock,  adrenalin  in,  36 

saline  infusion,  efTect  in,  36 
stimulants  in,  action  of,  36 
surgical,  34 
treatment  of,  36,  37 
vasomotor  nerves  in,  34 
vicious  circle  in,  35 
Sinus  venosus,  11 
in  batrachians,  14 
in  fish,  14 
in  reptiles,  14 
Suture,  of  heart,  accidents  that  have 
occurred  during,  171 
ana;sthesia  in,  171 
analysis  of  cases  reported,   170- 

173 
entrance  for,  171 
cases  reported  of.  156-159 
causes  of  death  in,   172 
Suturing  of  heart,  caution  in,  20 
material  used,  172 
mortality  in,  172 
prognosis    best,    what    age,    172, 

173. 
resulting    in    recovery,    157-160, 
162,  163,  166 


Suturing  of  heart,  time  of  operation 

after  injury,  171 
Syphilis,  heart,  206 

associated  conditions,  206 

cases  reported,  207 

character  of  gummata,  207 

forms  of,  207 

myocarditis,  due  to,  206 

prognosis,  206 

time  after  initial  lesion,  206 

valvular  lesions,  due  to,  206 
of  lung,  411 

abscess,  caused  by,    411 

bibliography  of,  417 

cases  reported,  411 

differential  diagnosis  of,  399 

gangrene,  caused  by,  411 
Systole,  force  of,  26 

Temperature,   extremes   of,   to   in- 
duce heart  action,  153 
Terminology,  of  heart,  5 

of  lung,  279 
Thoracic  duct,  injury  to,  336 
Tracheotomy,  see  Operations 
Transfusion,    amount   of  blood   that 

may  be  safely  used,  27 
Trichina  spiralis,  233 

cyst  of,  description  of,  464 
in  heart,  233,  234 
location  in  man,  464 
of  lung,  bibliography  of,  465 
operation  for,  464 
treatment  of,  464 
mode  of  infection,  234 
Tuberculosis,  in  heart,  bibliography 
of,  239 
cases  reported,  238 
forms  of,  237 
where  located,  238 
of  lungs,  per  cent,  of  recoveries  af- 
ter operation,  277 
Tumors,  angcioma,  of  heart,  216 
bibliography  of,  217 
cases  reported  of,  217 
course  of,  216 
position  of,  216 
benign,  of  heart,  213 
benign,    of    lung,    cases    reported, 

422 
carcinoma,  of  heart,  224 
bibliography  of,  226 
cases  reported,  225 
location  and  varieties,  224 
carcinoma  of  lung,  432 
bibliography  of,  435 


INDEX 


509 


Tumors,  carcinoma  of  lung,  cases  re- 
ported, 432 

pathology  of,  434 

prognosis  of,  434 

rapidity  of  growth,  432 

treatment  of,  435 
chondroma,  of  lungs,  423 

treatment  of,  425 
dermoids,  of  lung,  424 

treatment  of,  425 
division  of,  422 
fibroma,  of  heart,  213 

bibliography  of,  214 

cases  reported,  213 
lipoma,  of  heart,  215 

age  and  sex,  215 

bibliography  of,  216 

cases  reported  of,  216 

varieties  of,  215 
lymphoma,  of  lung,  422 

pathology  of,  423 

treatment  of,  425 
malignant,  of  lung,  426 

bibliography  of,  428 

cases  reported  of,  426 
myxoma,    of    heart,    bibliography 
of,  218 

cases  reported,  218 

description  of,  218 
osteoma,  of  lung,  423 

causes  of,  424 

influence  of  heredity,  424 

removal  of,  indications  for,  424 

structure  of,  423 

treatment  of,  425 

varieties  of,  423 
polypi,  in  bronchus,  402 

cases  reported,  403 

efifect  of,  402,  403 

frequency  of,  402 

possible  outcome  of,  402 

symptoms  of,  403 
polypi    of    heart,    bibliography   of, 
220 

cases  reported,  219,  220 

description  of,  218 

position,  219 
polypi  of  lung,  403 
rhabdomyoma,  217 

position  of,  217 
sarcoma  of  heart,  bibliography  of, 
224 

c-ases  reported,  223 

description  of,  223 

outcome  of,  223 

varieties  of,  223 


Tumors,   sarcoma    of  lung,   bibliog- 
raphy of,  431 
cases  reported,  430 
frequency  of,  429 
haemorrhage  in,  430 
pathology  of,  430 

Valves,  abnormalities  of,  78 
Vasomotor    centres,    circulation    to, 
effect  when  interfered  with,  35 
infusion,  effect  of,  on,  36 
Veins,  anomalies  of,  8 
in  batrachians,  13 
in  birds,  14 
blood  pressure  in,  26 

effect  of  changed  position  on,  27 
bronchial,  termination,  284 
in  cetacea,  13,  14 
contractile,  14 
differ  from  arteries,  13 
in  eel,  14 
in  heart,  17,  20 
in  monotremes,  13 
negative  pressure  in,  26 
in  porpoise,  13 
pulmonary,  44 

course,  in  lungs,  286 
origin,  286 

receive     venous     radicles     from 
lung,  284 
in  rabbits,  13 
in  Thyxine,   14 

vena  azygos,  ligation  of,  in  opera- 
tions, 285 
receive  branches  from  lung,  284 
vena  cava,  abnormalities  of,  42,  46 
in  birds,  8 

in  lower  mammals,  8 
vena  porta,  analogous  to,  8 
Venesection,  in  treatment  wounds  of 

lungs,  336 
Venous    system,    of    fish,    compared 

with  embryo,   14 
Ventricles,  atresia  of,  46 
contraction  of,  21 
fibroid  tumors  of,  213 
independent  action  of,  22 
negative  pressure  in,  25,  26 
relative  force  of,  10 
relative  thickness  of,  10 
relative    work    of    right    and    left, 

26 
rupture  of,  cause  of,  96 
rupture  of  right,  120-123,  125 
rupture  of  left,  120,  121,  125 
total  work  of,  26 


5IO 


INDEX 


Ventricles,  wounds  of,  relative  mor- 
tality, right  and  left,  146 
Vertebral  artery,  in  llama,  12 
Vessels,  effect  on,  of  adrenalin,  37 
transposition  of,  44 
transposition    of    aorta    and    pul- 
monary artery,  45,  47 
Viscera,  transposition  of,  44 


Wounds,  of  aorta,  94,  95 
of  auricles,  91-96 
of  bronchus,  treatment  of,  478 
of  chest,  gunshot,  322-329 
of  coronary  artery,  95 
gunshot,  bibliography  of,  329 
comparative  study  of,  in  civil  and 

Spanish-American   wars,   326 
table  of,  during  civil  war,  327 
tables  showing  mortality  in  war, 

treated  by  digitalis,  in  war,  325 
treated  by   venesection,   in  war, 

325 

of  diaphragm,  323 

of  heart,  91-96,  98,  125 
cases  reported,  91 
causes  of  death  in,  146,  155 
complication  in,  146 
conclusions    regarding    surgical 

treatment  of,  163,  165 
extra  pericardial,  92,  146 
factors  of  importance  in,  148 
mortality  from,  146 
most  often  caused  by,  91 
recovery  from,  92,  94,  96,  97 
reports  of,  in  civil  war,  93 
surgical  treatment  of,  151 
symptoms  of,  148-150 
tables  concerning,  97,  98 
treatment  of,  150 

of  liver,  95 


Wounds,  of  lung,  best  mode  of  oper- 
ating, 475 
bullet,  aseptic,  322,  328 
cases  reported,  322 
cause  most  frequent,  322 
causes  of  death,  336 
with  complications,  332-334 
chest  hermetically  closed,  result 

of,  325 
effects  of,  297 
with  emphysema,  331 
fever  in,  335,  336 
fixation  of  chest,  value  of,  in,  337 
with  formation  ossiform  concre- 
tions, 331 
haemorrhage  in,  334 
lacerated  and  incised,  330 
bibliography  of,  339 
cases  reported,  330 
laceration  of,  without  fracture  of 

ribs,  331 
prognosis  of,  336 
recoveries  from,  330-333 
recovery     after     gunshot,     some 

cases  reported,  322-324 
reports  chest  wounds,  civil  war, 

326 
resulting  in  fistula,  324 
symptoms  of,  334 
symptoms   of  lung   bleeding   in, 

334 
treated  by  thoracentesis,  331 
treatment  of,  336,  480 
treatment  of,  essentials  of,  480 
venesection  in  treatment  of,  336 

paracentesis,   with  injury  of  heart 
and  recovery,  96 

of  pericardium  only,  93-95 

pleural  effusion,  caused  by,  324 

of  thoracic  duct,  336 

of  vena  cava,  95 

of  ventricles,  91-96,  98,  125 


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The  surgery  of  the  heart  and 
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'^^^  ^^,l.9,^%9.Uhe  heart  and  lungs, 


2002245400 


vKvW  /Is.v.w.ViS 


